The Less They Know, the Better

I. Summary

With funding coming
in now, for any youth activities, if you talk about abstinence in your
proposal, you will get the money.Everybody knows that.

-A
teenager working with youth in Kampala

We don't think
abstinence is really working in our communities.We work with children in primary five through
seven who are engaging in sexual activities.We always come with the message to delay sexual debut.But for most children here, this is not
enough.

-Youth
leader in Kabarole

Widely hailed as a leader in the prevention of human
immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), Uganda
is redirecting its HIV prevention strategy for young people away from
scientifically proven and effective strategies toward ideologically driven
programs that focus primarily on promoting sexual abstinence until
marriage.Although endorsed by some
powerful religious and political leaders in Uganda,
this policy and programmatic shift is nonetheless orchestrated and funded by
the United States
government.Pioneered in the United
States in 1981, "abstinence until marriage" programs (also known as "abstinence
only" programs) teach that abstaining from sex until marriage is the only
effective method of HIV prevention and that marriage between a man and a woman
is the expected standard of human sexual behavior.Numerous U.S.-funded studies have shown these
programs to be ineffective at changing young people's sexual behaviors and to
cause potential harm by discouraging the use of contraception.The effect of Uganda's new direction in HIV
prevention is thus to replace existing, sound public health strategies with
unproven and potentially life-threatening messages, impeding the realization of
the human right to information, to the highest attainable standard of health,
and to life.

Despite a reported dramatic drop in HIV prevalence in Uganda
in the 1990s, from an estimated 15 percent nationally in 1992 to 6 percent in
2002, Ugandans of all ages continue to face a high risk of HIV infection.Ugandans tend to start having sex at an early
age and with little sex education.Demographic and health surveys show that over half of Ugandan girls have
had sex by age seventeen, usually with someone older.Among girls who marry before the age of
eighteen, most marry men who have been sexually active for several years, often
without having used condoms.These and
other factors make it vitally important to educate young people about HIV and
to caution girls at an early age about the risks of HIV infection in
marriage.Abstinence-until-marriage
programs fail on both of these counts.Not only do they fail to offer young people information about condoms
and safer sex on the grounds that this would undermine the goal of abstinence,
they additionally promote marriage to young people while withholding
information on its inherent risks.

Uganda's
increasing embrace of abstinence-only approaches is manifest on many levels,
from the office of the president to the halls and classrooms of the nation's
primary and secondary schools.In
November 2004, the Uganda AIDS Commission (UAC) released a draft "Abstinence
and Being Faithful (AB)" policy to guide the implementation of
abstinence-until-marriage programs throughout the country.Intended as a companion to the country's
existing strategy on the promotion of condoms, the policy in fact undermines
condoms as an HIV prevention measure and suggests that promoting condoms
alongside abstinence messages would be "confusing" to youth.The document contains virtually the same
definition of "abstinence education" as in legislation governing abstinence-only
programs in the United States,
suggesting that Uganda's
programs will replicate programs that have been proven ineffective in numerous U.S.
states.As an HIV prevention strategy
for married people, the document proposes compulsory HIV testing for all
couples intending to marry-a strategy that not only infringes on the right to
informed consent but, as discussed further below, fails to address the ongoing
risk of HIV faced by married women.

In 2001, the Government of Uganda launched an ambitious
program to expand HIV prevention education to all of the country's primary and
secondary schools.Funded by the United States
and known as the Presidential Initiative on AIDS Strategy for Communication to
Youth (PIASCY), the program provides abstinence-until-marriage messages through
a series of assembly messages, classroom activities and youth rallies.PIASCY materials were developed through a
series of stakeholder meetings in Uganda that included public health
experts, experienced HIV/AIDS educators, community and faith-based organizations,
and others.Numerous participants
observed that religious groups exercised an effective veto over the inclusion
of objective health information, including images depicting ejaculation, body
changes during puberty, the effectiveness of condoms, and even proper cleaning
of the foreskin.At the insistence of
these groups, pre-tested PIASCY materials were withdrawn from circulation and
re-released with several explicit images purged and a chapter on "ethics,
morals and cultural values" added.These
developments occurred at the same time the U.S. Agency for International
Development (USAID) had placed a technical adviser at the ministry of education
to oversee PIASCY.Draft secondary
school materials, under revision as of this writing, contain numerous falsehoods
about condoms (including the claim that they contain microscopic pores that are
permeable by HIV pathogens) and caution that premarital sex is "against
religion and norms of all cultures in Uganda" and "is considered a form
of deviance or misconduct."

Finalized PIASCY materials for primary schools included some
information about condoms, which is consistent with a recently drafted strategy
of the Uganda Ministry of Health calling for the promotion of condom use to
"all sexually active people."However,
teachers interviewed by Human Rights Watch said that USAID-funded PIASCY
trainers had encouraged them to omit information about condoms in favor of an
abstinence-only message.The political
climate favoring abstinence-only approaches in Uganda, including numerous
anti-condom statements by President Yoweri Museveni in 2004, also influenced
school teachers to teach abstinence as an exclusive method of HIV
prevention.Because of a 1997 Ugandan
policy guaranteeing free primary education to everyone in the country, many
children who had dropped out of school, returned and so an unusually high
proportion of Ugandan primary school students are in their teens.This makes it especially important for the
president and foreign donors not to contradict or undermine the health
ministry's policy of promoting condoms to everyone who needs them.

Outside of schools, Human Rights Watch found that
abstinence-only approaches were being promoted in Uganda through government-sponsored
youth rallies and additionally, in programs run by community and faith-based
organizations.At at least one rally,
participants were told that "using a condom with a person with these [sexually
transmitted] diseases is like using a parachute which opens only 75 percent of
the time."Blending health messages with
politics, participants were also encouraged to promote President Museveni, in
power since 1986, in his bid for a third term.As of November 2004, the U.S.
embassy in Uganda
had budgeted approximately U.S.$8 million for "abstinence and behavior change"
programs for young people, of which approximately U.S.$3 million was for
PIASCY.One national organization
already receiving U.S.
support to carry out abstinence programs was the National Youth Forum run by
First Lady Janet Museveni, perhaps the best-known proponent of abstinence-only
programs in Uganda.Mrs. Museveni has described abstinence-only
approaches as a blend of African and Christian values and has used her position
of influence to intimidate organizations that promote condoms to young
people.On World AIDS Day 2004, she
called for a national "virgin census" to support her abstinence-only efforts,
raising fears that children would be forced to submit to intrusive medical
tests or otherwise disclose confidential information about their virginity
status.

With the growth of abstinence-only approaches in Uganda, there
are growing indications that condoms will gradually disappear from the
country's HIV/AIDS strategy.In October
2004, the Ministry of Health issued a nationwide recall of all free government
condoms, allegedly in response to failed quality control tests.The ministry then took the extraordinary step
of requiring post-shipment quality control testing on all condoms imported into
Uganda,
including those that have already been tested.By December 2004, experts were forecasting a national condom
shortage.Rather than take steps to
address the shortage, however, Uganda's minister of state for primary health
care stated, "As a ministry, we have realized that abstinence and being
faithful to one's partner are the only sure ways to curb AIDS.From next year, the ministry is going to be
less involved in condom importation but more involved in awareness campaigns;
abstinence and behavior change."

This statement was only the latest in a series of
anti-condom statements from senior government officials in Uganda.Throughout 2004, including at the
International AIDS Conference in Bangkok,
Thailand,
President Museveni lashed out against condoms as inappropriate for Ugandans and
suggested that condom distribution encouraged promiscuity among young
people.First Lady Janet Museveni has
criticized groups that distribute condoms to young people for "pushing them to
go into sex" and stated that "it is not the law that our children must have
sex."Non-governmental organizations
that have traditionally promoted condoms in Uganda told Human Rights Watch they
feared provoking the ire of political leaders if they continued their work,
while those that deny the effectiveness of condoms have enjoyed unprecedented
levels of government support."We don't
want to be seen to be doing what government or political leaders are opposed
to," the coordinator of a youth HIV prevention program told Human Rights
Watch."We fear we would be blacklisted."

In numerous interviews, Human Rights Watch found that an
exclusive focus on sexual abstinence as an HIV prevention strategy failed to
account for the lived experiences of countless Ugandans."I got HIV in marriage.I was faithful in my relationship," said one
Ugandan woman, expressing a common predicament.Indeed, the suggestion that marriage provides a safeguard against HIV
may amount to a death sentence for women and girls.Ugandan women face a high risk of HIV in
marriage as a result of polygyny and infidelity among their husbands, combined
with human rights abuses such as domestic violence, marital rape, and wife
inheritance (whereby a widow is forced to marry the brother of her late
husband).While surveys suggest that
Ugandan women are more likely to refuse sex with a husband who has an STD than
women in other African countries, it is still widely believed in Uganda that
women have no right to deny their husbands sex.Research by Human Rights Watch and others has shown that many Ugandan
women who abstain until marriage and remain faithful to their husbands
nevertheless face a very high risk of HIV because of their husbands' infidelity
or prior HIV infection.Although abuses
against married women may put them at equal risk of HIV as their unmarried
counterparts, abstinence educators nevertheless champion the institution of
marriage while at the same time withholding information about its risks.

Abstinence-only programs also fail to recognize that, as in
all countries, AIDS in Uganda
is a disease of poverty.Many Ugandans
live on less than U.S.$1 per day, a situation that has been exacerbated by
decades of political violence and civil war.New HIV cases occur among girls trading sex for school fees, women
enduring violent marriages because they lack economic independence, and orphans
being pushed onto the street and sexually exploited."I wish those who preach abstinence would
come down to the slums and see how people are living," said one AIDS educator."These girls live five to a room.There is no supper for them.The man outside says he will get her money
and a place to sleep.Now, what is she
going to do, abstain?"Others noted that
abstinence-only messages had no relevance for people who did not marry, not
least lesbian, gay, bisexual, and transgender (LGBT) Ugandans whose very
existence is denied by their government.LGBT communities are "erased from all HIV programs," said one
activist."The Uganda AIDS Commission
does not want to hear about them."

As the largest single donor to HIV/AIDS programs in Uganda, the United States is using its
unparalleled influence to export abstinence-only programs that have proven to
be an abject failure in its own country.No less than twelve U.S.
government-funded evaluations at the state level have shown that U.S.-based
abstinence-only programs have little influence on participants' sexual behavior
and may cause harm by discouraging the use of contraception.Additional studies have suggested that
"virginity pledges," a staple of abstinence-only programs in which young people
promise to abstain until marriage, often fail and may result in lower
contraceptive use (and higher STD rates) among sexually active unmarried
youth.Officials in both the U.S.
and Ugandan governments have ignored these studies.Instead, they have misleadingly used national
survey data to suggest that abstinence and fidelity are more popular among
Ugandans than condom use.Not only do
such data provide a poor substitute for evaluation of abstinence programs, but
research in Uganda clearly indicates that a comprehensive approach to HIV
prevention-one emphasizing positive behavior change, high-level political
leadership, condom use, widespread HIV testing, and a myriad other factors-is
what allowed the country to reduce HIV prevalence in the 1990s.Nothing in the demographic or historical
record suggests that "abstinence education" as conceived by the United States is what contributed to Uganda's
HIV prevention success.

Government officials in both Uganda
and the United States
routinely characterize Uganda's
HIV prevention strategy as "ABC," where A stands for abstinence, B for being
faithful, and C for condom use.This
acronym is designed in part to give the impression that Uganda has always encouraged abstinence as part
of its anti-AIDS efforts, and that abstinence contributed significantly to
marked declines in HIV prevalence in Uganda in the 1990s.Again, this impression is misleading.Delayed sexual debut was and continues to be
one of many messages provided by Ugandan AIDS educators; however, Uganda did not implement abstinence education on
a large scale until the United
States began promoting these programs
internationally around 2001.Moreover,
there is scant evidence that abstinence (as opposed to other behavior changes)
contributed significantly to reported declines in HIV prevalence in Uganda
in the 1990s.Many veteran AIDS
educators in Uganda told
Human Rights Watch they had never heard of "ABC" until the United States branded Uganda's success with this
alphabetical sound-bite.While ABC
proponents have been able to uncover elements of Uganda's
AIDS strategy that support the ABC model, the definition of ABC in the 2003 U.S.
global AIDS strategy-Abstinence for youth, Be faithful for married couples, and
Condoms only for "high risk" populations-is a uniquely American invention.

At this writing, an estimated 6 percent of the adult
population in Uganda
is infected with HIV, significantly less than the estimated 15 percent national
prevalence a decade ago.Uganda
has been rightly praised for this achievement.However, the country still faces a generalized HIV/AIDS epidemic and
cannot afford to attack proven HIV prevention strategies and adopt discredited
ones.Uganda is home to nearly 1 million
children orphaned by HIV/AIDS, many of them at high risk of HIV infection
themselves.Efforts to expand access to
antiretroviral treatment for people living with HIV/AIDS still have a long way
to go, making it especially important to sustain effective and widespread HIV
prevention measures.As an acknowledged
leader in HIV prevention, Uganda
should be building on its success, not adopting the United States' failures.

II. Recommendations

To
the Government of Uganda

Replace programs that promote
abstinence-until-marriage to the exclusion of other effective HIV
prevention strategies.Use
instead comprehensive programs that provide complete, factual, and
unbiased information about HIV prevention, including information about the
correct and consistent use of condoms.Encourage bilateral donors to redirect funding away from
abstinence-until-marriage programs towards comprehensive programs.Until such time as
abstinence-until-marriage programs can be replaced, ensure that nothing in
these programs undermines effective strategies for HIV prevention.

Integrate the draft "Abstinence and
Being Faithful (AB)" policy into existing HIV prevention strategies to
avoid any conflict between them.Remove any information from the policy that suggests that teaching
young people about safer sex contradicts, confuses, or undermines the
message of abstinence.Recognize in
all HIV prevention programs and policy documents that marriage does not
provide a guarantee of safety against HIV.

Rescind the recommendation of
compulsory HIV testing for couples intending to marry found in the AB
policy.Consistent with public
health and human rights standards, encourage instead universal access to
voluntary HIV testing and counseling.

In school-based programs, ensure that
school teachers are adequately informed about the prevalence of sexual
activity among young Ugandans and qualified to provide objective, unbiased
HIV prevention information and counseling to sexually active pupils and
students.Ensure that such
messages (including about condoms) are not contradicted by political
leaders.Take steps to supplement
HIV prevention messages given in school assemblies with in-class lessons
and activities promoting assertiveness, self esteem, and other life skills
outlined in the school curricula.Involve pupils and students in the implementation of school-based
HIV prevention programs and the evaluation of materials.

For secondary school HIV prevention
materials, ensure scientific accuracy and age-appropriate HIV prevention
information, in addition to messages of abstinence.Remove references to non-marital sex as
a form of deviance.Ensure that
materials also assist young people who cannot legally or who do not marry,
including lesbian, gay, bisexual, and transgender youth.Finalize curricular materials and take
measures to avoid granting effective veto power to any particular
religious or political point of view.

Ensure that HIV prevention programs
conducted out-of-school provide complete, science-based information.Enforce a requirement of scientific accuracy
for the delivery of all HIV prevention information, whether by secular or
faith-based organizations.Enact a
clear policy opposing human rights violations against grantees or
sub-grantees of HIV prevention funds, including "virgin censuses," discrimination
against lesbian, gay, bisexual, and transgender youth, and discrimination
against those who hold opposing religious views.

Ensure that the special needs of
vulnerable populations, including orphans and children affected by AIDS,
internally displaced persons, street children, and lesbian, gay, bisexual,
and transgender persons, are explicitly recognized in national and local
HIV prevention policies and programs.Recognize the inherent limitations of abstinence-until-marriage
messages for these populations and withdraw support from these programs
accordingly.

To reduce women's vulnerability to
HIV/AIDS, enact and enforce laws that protect women and girls from
violence and discrimination.These include laws that criminalize marital rape and that guarantee
women's equal property rights.Ratify the protocol on women's rights under the African Charter on
Human and People's Rights.

Recognize the link between the spread
of HIV/AIDS and discrimination based on sexual orientation, including the
criminalization of same-sex relations.Repeal sections 140, 141, and 143 of the Penal Code which
criminalize same-sex relations between consenting adults and are sometimes
used as a justification for failing to provide life-saving HIV prevention
information and services to lesbian, gay, bisexual, and transgender
youth.

Take urgent steps to ensure an
adequate supply of free and low-cost condoms in Uganda to assist HIV
prevention efforts.In light of
the recent recall of government-funded condoms due to apparent quality
control problems, urgently seek relief from international donors to fill
the condom supply gap.Make
publicly available all information about the condom recall, the steps the
government is taking to address it, and how the public can obtain free
condoms in the interim.Consistent
with the National Condom Policy and Strategy (2004), ensure that all
sexually active or potentially sexually active individuals, not just
select populations, are targeted by condom promotion campaigns.

To
the Government of the United States

To the U.S. Congress

Repeal sections 402(b)(3) and 403(a)
of the United States
Leadership Against HIV/AIDS, Tuberculosis and Malaria Act.These provisions require the
expenditure of 33 percent of HIV prevention funds on abstinence-until-marriage
programs that exclude consideration of other approaches to HIV
prevention.In light of existing
government-funded evaluations showing abstinence-only programs to be
ineffective and potentially life-threatening, enact legislation prohibiting
the expenditure of federal funds on these programs pending further
research and evaluation.

Redirect U.S. funding for
abstinence-until-marriage programs to proven interventions that guarantee
young people complete information about HIV prevention, including the use
of condoms.Encourage the U.S.
Office of the Global AIDS Coordinator to revise sections of the U.S.
global AIDS policy that make false claims about the effectiveness of
abstinence-only programs and promote abstinence-until-marriage as an HIV
prevention strategy for young people.Ensure that age-appropriate information about condoms and condom
promotion strategies are provided to all youth and not limited to
"high-risk" populations.

Request and publicly disclose
information from the global AIDS office about all international funding
for abstinence-until-marriage programs.Include regional and national-level
funding as well as grantees and sub-grantees.Enforce policies prohibiting the use of U.S.
federal funds for religious proselytizing, political purposes, or the
provision of medically inaccurate information.Ensure that all HIV prevention programs
for youth are evaluated according to their short and long-term impact on
young people's sexual knowledge, attitudes, intentions, and behaviors, as
well as trends in HIV transmission, and make these evaluations public.

Request and publicly disclose
information from the global AIDS office about all international funding
for HIV prevention programs for young people other than
abstinence-until-marriage programs.These include programs that combine abstinence messages with
factual information about condom use and safer sex, seek to enhance
women's sexual autonomy and empower them to refuse sex and insist on
fidelity or condom use, and/or address human rights violations that
increase women's vulnerability to HIV/AIDS, including in marriage.

To
the Presidential Emergency Plan for AIDS Relief (PEPFAR) country team in Uganda

Urge the removal of any scientifically
inaccurate information from HIV prevention materials in Ugandan secondary
schools.Withhold any funding
for materials that provide false or misleading information, and support
the publication of texts that contain complete and science-based HIV
prevention messages.End support
for HIV prevention materials, programs, or organizations that present
heterosexual marriage as the sole legitimate context for sex or that
directly or indirectly present marriage as providing safety from HIV
infection.

Evaluate the provision of HIV
prevention messages in schools, with particular attention to whether
teachers are censoring sensitive information contained in approved texts.Encourage political leaders not to
contradict information in school materials.Ensure that U.S.-funded training
programs do not discourage teachers from discussing condoms or otherwise
promote an abstinence-only agenda.In U.S.-funded training sessions, remind teachers to answer all
students' questions about safer sex and condom use, as stipulated in
approved texts.

Evaluate the impact of U.S.-funded HIV
prevention programs for Ugandan youth.Include an evaluation of whether these programs affect young
people's knowledge, attitudes, intentions, and behaviors related to sexual
activity.Review existing programs
to ensure that no HIV prevention money is being used for reasons other
than intended, and investigate any misuse of HIV prevention funds, such as
for partisan political activities, religious proselytizing, or virginity
testing.Withhold support from
projects that so misuse HIV prevention funds.

Take immediate steps to counter all
misinformation about condoms, including by government and private actors.Withhold funds from organizations that
make false or misleading statements about condoms or actively discourage
them as an HIV prevention strategy.Together with other donor governments, immediately import a
sufficient number of condoms to ensure an adequate supply for free condoms
until such time as safe and tested condoms are available through the
national distribution program.

To
the Office of the Global AIDS coordinator (OGAC) of the U.S. government

Provide a full accounting of existing
funding for youth HIV prevention programs.This should include programs
administered regionally through Track 1.0 and in national programs through
Track 2.0 of PEPFAR.Withhold
funding from any grantee or sub-grantee that uses U.S. HIV prevention
funds to provide false or misleading scientific information, engage in
religious proselytizing, engage in partisan political activity, or
discriminate against individuals based on their sexual orientation.

Cooperate with requests by individuals
or government agencies to make publicly available all information on
abstinence-until-marriage programs.Provide information about national and regional funding for these
programs, grantees and sub-grantees, and details about their
activities.Establish a public
mechanism for monitoring the effectiveness of HIV prevention programs, and
include a wide range of civil society groups in this process.

To
all other donors to Ugandan AIDS programs, including the Global Fund and
U.N. agencies

Review existing HIV prevention
programs in Uganda.Ensure that funding is not provided to
individuals or groups that deny young people factual information about HIV
prevention, discriminate against marginalized communities such as sexual
minorities, or use HIV prevention funds to engage in religious
proselytizing.

Develop a public position on
U.S.-funded abstinence-until-marriage programs.Evaluate the impact of these programs on
the availability of effective interventions such as comprehensive sex
education, life skills programs that emphasize girls' empowerment and
negotiation skills, and programs that address HIV risk among especially
vulnerable communities.Evaluate
the feasibility of compensating for this loss through increased funding
and technical support to proven interventions.

To reduce women's vulnerability to
HIV/AIDS, support legal reforms that protect women and girls from violence
and discrimination.Reforms
should include protections against marital rape and unequal access to
property.Support programs that
promote women and girls' sexual autonomy and economic empowerment,
including job training and credit programs.

Work with the government of Uganda
to address the current condom supply shortage.Together with other donors, immediately
provide a sufficient number of condoms to cover the current shortage until
such time as safe and tested condoms are available through the national
distribution program.

III.
Methods

This report is based on information gathered in Uganda in
November 2004 as well as extensive prior and subsequent research.Two Human Rights Watch researchers
interviewed children and young adults in and around Kampala, Mbale, Mbarara, Kabarole, and
Kasese.At schools, we spoke with dozens
of pupils, teachers, headteachers, and members of AIDS clubs.For out-of-school children and young adults,
we worked through nongovernmental organizations providing health and education
services to children and assistance to street children, child laborers, and sex
workers.Most interviews were conducted
in English; translation was provided for young people whose first language was
Luganda or Rutooro.

In Kampala,
Human Rights Watch interviewed representatives of the president and first
lady's offices, as well as representatives from the ministries of health and
education.We spoke with officials of
various United Nations agencies, the U.S. government, the Uganda AIDS
Commission, and the Uganda Human Rights Commission.We collected information from health service
providers, religious leaders, academics, nongovernmental organizations, and
Ugandan AIDS activists.Secondary
sources from peer-reviewed published literature, NGO reports, and other materials
supplemented what we gathered in Uganda.All materials cited in this report are either
publicly available or on file at Human Rights Watch.

For HIV prevention programs supported by the U.S. Agency for
International Development (USAID), "youth" is defined as those aged fifteen to
twenty-four.In Uganda, youth has been defined as
anyone aged fifteen to thirty, or any young person who is not yet married.The term "youth" has no legal definition in
international human rights law, though "child" refers to anyone under the age
of eighteen.[1]In this report, we use the terms "youth" or
"young people" to describe those targeted in prevention programs in Uganda,
and "child" when referring to those under eighteen.

IV. Background

Young
people and HIV/AIDS in Uganda

Young people in Uganda have never known a world
without HIV/AIDS.Since 1982, when the
country's first cases of HIV were detected on the shores of Lake
Victoria in Rakai district, AIDS has killed an estimated 940,000
Ugandans, including 78,000 in 2003 alone.Most of these have been men and women of childbearing age, leaving close
to one million Ugandan children without parental care, in addition to those
whose parents are sick or dying.The
impact of AIDS on children and young people is seen in their own risk of HIV
infection: as AIDS impoverishes families, young people-especially young
girls-are likely to be withdrawn from school and forced into exploitative
situations to survive.Ignorance and
denial fuel HIV even further, leaving young people without the critical
information that could help them prevent infection.As of 2002, according to government
estimates, HIV prevalence among young people in Uganda stood at an estimated 4.9
percent, with rates of 6.5 percent in major towns and 4.1 percent in rural
areas.[2]

Although Uganda
is widely recognized as the only country in sub-Saharan Africa
to experience a significant drop in HIV prevalence, the extent of this decline
has been exaggerated.[3]The Joint United Nations Programme on
HIV/AIDS (UNAIDS) estimates that national HIV prevalence in Uganda fell from 12
percent in the early 1990s to just over 4 percent in 2003, though some of this
decline is due to HIV-related deaths.[4]Declines in urban areas have been more
dramatic, from approximately 30 percent in three sites in 1992 to an average of
9.1 percent at the same three clinics in 2002.[5]Local organizations working with communities
affected by AIDS have challenged recent government figures as too low and
estimated HIV prevalence to be between 10-17 percent nationally.[6]In addition, reported declines in national
HIV prevalence may mask some regional and demographic variations.In three sentinel sites-Mbarara, Mbale, and
Kilembe-HIV prevalence between 2001 and 2002 either stagnated or rose.HIV rates tend to be consistently higher in Uganda's
urban areas than in rural ones-8 percent compared to 5 percent among the
general population, and 6.5 percent compared to 4 percent among young
people.

Uganda's
success against AIDS has not been felt equally by those at highest risk of
infection.In Gulu, in northern Uganda
where there has been a protracted and brutal civil war since 1986, HIV
prevalence in 2002 was estimated at 12 percent in the general population and 8
percent among young people; the general figure is higher than in 2001, although
rates are lower than in the early 1990s.[7]HIV prevalence among military recruits
increased from 3 percent to 13 percent in five sites from 1997 to 1999.[8]The highest HIV prevalence in Uganda
is found among sex workers, 47 percent of whom were HIV-positive in a 2002
survey compared to 28 percent in 2000.[9]According to data collected by the AIDS
Information Centre (AIC), a leading nongovernmental organization in the field
of voluntary HIV counseling and testing (VCT), a significant percentage of
women in sex work are girls aged fifteen to twenty-four.

The combination of economic, social, biological, and
behavioral factors that render young Ugandans vulnerable to HIV, especially
girls, is not perfectly understood.Sex
accounts for the vast majority of HIV infections in Uganda,
as in the rest of sub-Saharan Africa.Ugandans are estimated to have their first
sexual experience as teenagers, the median being 16.7 years for girls and 18.8
years for boys as of 2001.[10]By age seventeen, more than 50 percent of
Ugandan girls have had sex, usually with someone older.[11]Among girls aged fifteen to twenty-four, 31
percent report that their first sexual partner was three to four years older,
and 11 percent report that their first sexual partner was ten or more years
older.[12]According to the Uganda AIDS Commission,
"Ugandan youth begin sexual activity at fairly young ages and with little
sexuality information."[13]

The phenomenon of girls having sex with older men, often out
of economic need, is thought to account for a significant number of new HIV
infections in Uganda.Age disparities both increase the likelihood
of sexual coercion and limit girls' ability to demand fidelity and condom
use.Early sex may also lead to early
marriage: as of 2001, 32 percent of girls aged fifteen to nineteen in Uganda
had been married, compared to only 6 percent of boys.[14]Among married girls, a fifth were in
polygynous unions.[15]The combination of early marriage and
polygyny further increases girls' and young women's HIV risk, as men often
engage in concurrent sexual relationships without using condoms.The payment of bride price in connection with
many marriages fosters the perception that a husband "owns" his wife and can
demand sex from her without her consent.Domestic violence, which according to the United Nations affects 40
percent of Ugandan women, further inhibits girls' ability to control the terms
of their sex lives (including negotiating condom use) and exposes them to HIV.[16]In 2001, only 4 percent of married men in Uganda
reported having used a condom the last time they had sex, compared to 59
percent of unmarried men.[17]While most women knew that condoms would
protect them against HIV, only 27 percent of girls aged fifteen to nineteen and
36 percent of women aged twenty to twenty-four said they could convince their
partners to use them.[18]

In 2002, six girls in Uganda were reported infected with
HIV for every boy.[19]Of the estimated 530,000 Ugandans living with
HIV in 2003, over half were women and girls.[20]In Kampala, Uganda's capital city, the AIDS
Information Centre reported in 2002 that 10.3 percent of girls and women aged
fifteen to twenty-four seeking an HIV test for the first time tested positive,
compared to 2.8 percent of boys and men in that age group.[21]The AIC data also found that girls were
entering into prostitution at a young age: of 218 sex workers surveyed, 65
percent were girls and young women aged fifteen to twenty-four.

The
human right to HIV/AIDS information

HIV/AIDS is a disease that is fueled by stigma, denial, and
ignorance.While Uganda boasts high levels of
awareness of HIV-close to 100 percent of survey respondents in 2000 stated they
had heard of the disease[22]-dangerous
myths about HIV/AIDS persist.In the
same survey, close to one quarter of Ugandans who said they had heard of AIDS
agreed with the statement that HIV could be contracted from a mosquito bite.[23]Both men and women harbored discriminatory
attitudes towards people living with AIDS, such as the view held by roughly
half of Ugandans that a female teacher living with HIV should not be permitted
to go on teaching.[24]This is a disturbing finding in Uganda, where the stigma associated with AIDS is
thought to be less powerful than in Africa
generally.

Widespread awareness of HIV/AIDS in Uganda, moreover, does not
translate into knowledge of how to prevent infection-particularly among women
and girls.In 2001, some 13 percent of
Ugandan women did not know any method of avoiding AIDS, compared to 5 percent
of men.[25]Women were less likely than men to know that
condoms prevent HIV, less likely to know that limiting one's number of sexual
partners prevents HIV, and less likely to know that a healthy-looking person
can be infected with HIV.Women and
girls who were familiar with modes of HIV transmission were less likely than
men to put them to use: in 2001, 69 percent of girls aged fifteen to nineteen
said they knew condoms would protect them from HIV, whereas only 32 percent
said they could obtain them.The
corresponding figures for boys were 83 percent and 64 percent.Over 20 percent of young people surveyed in Kampala in 2002 believed
that those who used condoms were "promiscuous."[26]

Such gender disparities in knowledge of HIV prevention may
be explained partly by girls' unequal access to formal education.In 2001, over one-quarter of Ugandan women
without schooling knew no way of protecting themselves from HIV, compared to
only 2 percent of women who had attended secondary school or higher.[27]Yetwhile school has become more
accessible to Ugandans of both sexes in recent years, it continues to be less
accessible to girls.As of 2001, four
years into Uganda's
free education policy, 9 percent of Ugandan girls had never been to school
compared to 2 percent of boys.[28]Men were also more likely to stay in school,
with 66 percent of young men aged fifteen to nineteen in school in 2001,
compared to 44 percent of young women.[29]

Access to information about HIV/AIDS without discrimination
is not simply a public health imperative-it is a human right.International treaties ratified by Uganda
recognize that all people have the right to "seek, receive and impart
information of all kinds," including information about their health.[30]The United Nations Convention on the Rights
of the Child requires states to "ensure that all segments of society, in
particular parents and children, are informed, have access to education and are
supported in the use of basic knowledge of child health."[31]The Committee on the Rights of the Child, the
U.N. body responsible for monitoring the implementation of the Convention on
the Rights of the Child, states in its general comment on HIV/AIDS that
children have the right to access adequate information related to HIV/AIDS
prevention.The Committee has emphasized
that:

Effective HIV/AIDS prevention requires States to refrain
from censoring, withholding or intentionally misrepresenting health-related
information, including sexual education and information, and that, consistent
with their obligations to ensure the right to life, survival and development of
the child (art. 6) States parties must ensure that children have the ability to
acquire the knowledge and skills to protect themselves and others as they begin
to express their sexuality.[32]

Access to health information is also essential to realizing
the human right to the highest attainable standard of health and, ultimately,
the right to life.[33]Article 12 of the International Covenant on
Economic, Social and Cultural Rights (ICESCR) specifically obliges governments
to take all necessary steps for the "prevention, treatment and control of
epidemic . . . diseases," such as HIV/AIDS.[34]The Committee on Economic, Social and
Cultural Rights, the U.N. body responsible for monitoring the implementation of
the ICESCR, has interpreted article 12 as requiring "the establishment of
prevention and education programmes for behaviour-related health concerns such
as sexually transmitted diseases, in particular HIV/AIDS."[35]In language similar to that of the Committee
on the Rights of the Child, the ICESCR committee notes:

States should refrain from limiting access to
contraceptives and other means of maintaining sexual and reproductive health,
from censoring, withholding or intentionally misrepresenting health-related
information, including sexual education and information, as well as from
preventing people's participation in health-related matters. . . . States
should also ensure that third parties do not limit people's access to
health-related information and services.[36]

The United Nations International Guidelines on HIV/AIDS and
Human Rights, while not binding, similarly call on states to take positive
steps to "ensure the access of children and adolescents to adequate health
information and education, including information related to HIV/AIDS prevention
and care, inside and outside school, which is tailored appropriately to age
level and capacity and enables them to deal positively with their sexuality."[37]

Uganda and the U.S. Global AIDS Initiative

Ugandan AIDS policy is strongly influenced by the United States,
which significantly increased its international assistance to HIV/AIDS programs
in 2003.Under President George W.
Bush's Presidential Emergency Plan for AIDS Relief (PEPFAR), U.S. funding for HIV/AIDS programs in Uganda
doubled in 2004.[38]As of August 2004, the United States had budgeted approximately
U.S.$159 million for HIV/AIDS programs in Uganda for fiscal year (FY) 2005.[39]The legislation authorizing PEPFAR requires
that 55 percent of HIV/AIDS funds be used for the treatment of people living
with AIDS, 15 percent for care and support of people living with AIDS, and 20
percent for HIV prevention.Uganda's
U.S.-funded HIV prevention budget for FY2005 is therefore estimated at
U.S.$31.8 million.

For young people at risk of HIV/AIDS, the cornerstone of the
United States'
HIV prevention strategy is the promotion of sexual abstinence until
marriage."Abstinence until marriage"
programs are defined as programs whose sole purpose is to highlight the
benefits to be gained by abstaining from sexual activity until marriage, and
marriage is in turn held up as the expected standard of human sexual
activity.Abstinence-only approaches may
be contrasted with comprehensive sex education, which supports the choice not
to have sex but also includes information about condoms and other safer sex
options for young persons who are or who become sexually active.They may further be contrasted with
educational programs that caution young girls about sources of HIV risk in
marriage, such as infidelity, marital rape, domestic violence, polygyny, and
widow inheritance.Abstinence-only
approaches withhold information about the health benefits of condoms and
contraception (beyond their failure rates) in the belief that such information
contradicts the message of abstinence.

Despite numerous and unrefuted government-funded studies
discrediting abstinence-only approaches as an exclusive HIV prevention
strategy, the U.S. Congress requires that at least 33 percent of all HIV
prevention money under PEPFAR be spent on abstinence-until-marriage programs,
with the remainder spent on HIV testing and targeted outreach (including condom
promotion) for "high-risk" populations (defined as "prostitutes, sexually
active discordant couples (where only one partner is HIV positive), substance
abusers, and others"),[40] safe
blood and improved medical practices, and prevention of mother-to-child
transmission of HIV.[41]The U.S. government singles out
"faith-based organizations" as particularly qualified to implement
abstinence-until-marriage programs.The
U.S. Five-Year Global HIV/AIDS Strategy, the document that guides the
implementation of PEPFAR programs, elaborates on abstinence education as follows:

Delaying first sexual intercourse by even a year can have
significant impact on the health and well-being of adolescents and on the
progress of the epidemic in communities. . . . The strategies for youth . . .
encourage abstinence until marriage for those who have not yet initiated sexual
activity and "secondary abstinence" for unmarried youth who have already
engaged in intercourse.FBOs
[faith-based organizations] are in a strong position to help young people see
the benefits of abstinence until marriage and support them in choosing to
postpone sexual activity.Programs will
help youth develop the knowledge, confidence, and communication skills
necessary to make informed choices and avoid risky behavior.[42]

While U.S.
law does not explicitly define abstinence-until-marriage programs for the
purposes of PEPFAR, years of experience with similar programs in all fifty U.S. states
provides an indication of their main objectives.The U.S. government has funded
abstinence education domestically since 1981; in FY2004, appropriations for
these programs reached a historical high of U.S.$138.25 million.[43]All federally-funded abstinence-only programs
must meet an eight-part definition found in the 1996 Personal Responsibility
and Work Opportunity Reconciliation Act (commonly known as the Welfare Reform
Act), which defines "abstinence education" as follows:

"Abstinence education" means an educational or
motivational program which:

A.has as its exclusive purpose, teaching the
social, psychological, and health gains to be realized by abstaining from sexual
activity;

B.teaches abstinence from sexual activity outside
marriage as the expected standard for all school age children;

C.teaches that abstinence from sexual activity is
the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted
diseases, and other associated health problems;

D.teaches that a mutually faithful monogamous
relationship in context of marriage is the expected standard of human sexual
activity;

E.teaches that sexual activity outside of the
context of marriage is likely to have harmful psychological and physical
effects;

F.teaches that bearing children out-of-wedlock is
likely to have harmful consequences for the child, the child'sparents, and society;

G.teaches young people how to reject sexual
advances and how alcohol and drug use increases vulnerability to sexual
advances; and

H.teaches the importance of attaining
self-sufficiency before engaging in sexual activity.[44]

As discussed below, a slightly modified version of this
eight-part definition appears in a draft policy issued by the Uganda AIDS
Commission in November 2004 to guide U.S.-funded abstinence-until-marriage
programs in Uganda.[45]Many of the architects of the U.S. global AIDS strategy are the same
individuals who have a long history of supporting and implementing abstinence-only
programs in the United
States.

While numerous studies have demonstrated the ineffectiveness
of U.S.
abstinence-only programs, few have analyzed the content and delivery of
abstinence curricula to see what participants are actually being taught.[46]Analysis of these curricula is relevant to
the Ugandan context, as domestic experience with (and support for)
abstinence-only programs is largely what led the U.S. government to export these
programs abroad.In 2002, Human Rights
Watch published Ignorance Only: HIV/AIDS,
Human Rights and Federally Funded Abstinence-Only Programs in the United States, a case study of abstinence
education in the state of Texas.[47]The report disclosed numerous ways in which
U.S.-funded abstinence-only programs distort or otherwise restrict information
about condoms, impede participants' access to comprehensive HIV/AIDS
information and AIDS experts, and encourage young people to "pledge virginity"
despite the demonstrated risks of such pledges as an HIV prevention strategy.[48]In 2004, at the request of Congressman Henry
Waxman, the Special Investigations Division of U.S. House of Representatives'
Committee on Government Reform found scientific errors and distortions in
eleven abstinence-only curricula being used by sixty-nine federal grantees in
twenty-five U.S.
states.[49]The errors and distortions concerned, among
other things, the effectiveness of condoms against HIV and other STDs, the
health risks of sexual activity, and the causes of HIV transmission.

Studies such as these provide an important sign of what is
to come in countries like Uganda,
where the United States
has committed significant funds to abstinence-until-marriage programs.None of these studies is cited in any policy
document or publication related to abstinence-until-marriage programs in Uganda
or under PEPFAR, nor is any study demonstrating the effectiveness of
abstinence-only programs.

The acronym "ABC"-A for abstinence, B for being faithful,
and C for condom use-is often used to describe the U.S. (and Ugandan) approach
to preventing sexually transmitted HIV internationally.On the surface, ABC appears to promote
condoms alongside abstinence and fidelity as an effective HIV prevention
strategy.A closer examination of the
U.S. AIDS strategy, however, reveals that ABC is disaggregated as Abstinence
for unmarried youth, Being faithful for married couples, and Condom use for
"those who are infected or who are unable to avoid high-risk behaviors (such as
discordant couples (where only one partner is HIV positive))."[50]As noted above, the strategy defines
"high-risk" populations as "prostitutes, sexually active discordant couples,
substance abusers, and others."Thus,
for unmarried young people who are not working in prostitution, the
intervention message is abstinence only.Even where condoms are promoted to
"high-risk" groups, the strategy stipulates that condoms should not detract
from the overall message that "the best means of preventing HIV/AIDS is to
avoid risk all together"-that is, to abstain from sex until marriage.

The U.S. Global AIDS Strategy has evolved in a climate of
increasing censorship and distortion of information about condoms and safer
sex.[51]In 2002, the U.S. Centers for Disease Control
and Prevention (CDC) removed a fact sheet on the effectiveness of condoms from
its website and replaced it with a new fact sheet which, while factually
accurate, eliminated instructions on how to use a condom properly and evidence
indicating that condom education does not encourage sex in young people.[52]Information
on condom effectiveness was similarly altered on the website of the U.S. Agency
for International Development (USAID).[53]Guidelines proposed by the CDC in 2004
require that AIDS organizations receiving federal funds include information
about the "lack of effectiveness of condoms"
in any HIV prevention educational materials that mention condoms.[54]In 2002, the CDC erased from its website an
entire section entitled "Programs that Work," which had highlighted the
effectiveness of comprehensive sex education programs.[55]

Since taking office in 2001, President Bush has appointed as
high-level HIV/AIDS advisers physicians who deny the effectiveness of condoms
(either against AIDS or other STDs), such as Senator Tom Coburn and Joe S.
McIlhaney, Jr., president of the pro-abstinence-only Medical Institute for
Sexual Health (MISH) based in Texas.[56]Coburn, who has stated that "the American
people [should] know the truth of condom ineffectiveness, " served as co-chair
of the Presidential Advisory Council on HIV and AIDS (PACHA) until he was
elected to the U.S. Senate in 2004.He
was replaced by Anita Smith, a vocal advocate of abstinence-only programs.Coburn is also widely known for his efforts
to require cigarette-type warnings on condom packages stating that they offer
"little or no protection" against human papilloma virus (HPV), some strains of
which cause cervical cancer.[57]Condom use is in fact associated with lower
rates of cervical cancer and HPV-associated disease, though the precise effect
of condoms in preventing HPV is unknown.[58]McIlhaney's Medical Institute for Sexual
Health, which promotes abstinence-only sex education messages, produced a
comprehensive monograph on condoms stating that condoms do not make sex "safe
enough" to warrant their promotion for STD prevention despite overwhelming
evidence to the contrary.McIlhaney has
also stated in testimony before the U.S. Congress that there is "precious
little evidence" in support of comprehensive sex education programs.

V.
Findings on Abstinence Education in Uganda

We were told not to
show [pupils] how to use condoms and not to talk about them at our school.In the past, we used to show them to our
upper primary classes.Now we can't do that.

-A primary school teacher in
Kasese

In our assemblies
and in the classroom, we explain what abstinence is and why it is important . .
. . But around here, people don't buy this idea of abstinence because in Uganda,
many girls are using sex to buy their daily bread.

-A headteacher in Mbale

Uganda
stands out among African countries for its high-profile embrace of U.S.-funded
abstinence-until-marriage programs.The
country's early success in bringing down rates of HIV prevalence, combined with
its growing fundamentalist Christian population, has attracted the interest of U.S.
policymakers eager to demonstrate the success of abstinence-only programs.Support for abstinence-only approaches has
extended to powerful figures in Uganda,
most notably First Lady Janet Museveni, and can increasingly be found at the
level of schools and service providers.In what is widely viewed as a departure from his previous positions,
President Museveni has publicly supported abstinence-only approaches and,
before large international audiences, denigrated condoms as a means of HIV
prevention.All of this has occurred in
the context of a growing condom shortage in Uganda, prompting some government
officials to urge sexual abstinence to stave off a spike in HIV
transmission.These trends and their
impact on Uganda's
HIV/AIDS programs are documented below.

Uganda's official "AB" policy

In November 2004, Uganda claimed to be the first
country in the world to draft an official national policy on abstinence and
fidelity.Titled the "Uganda National
Abstinence and Being Faithful Policy and Strategy on Prevention of Transmission
on HIV," the draft policy is described by its authors as a companion to the
country's existing strategy on the promotion of condoms and a component of Uganda's
larger "ABC" strategy.[59]A review of the draft policy document,
however, shows that the policy's objective is to scale up abstinence-only programs styled after those in use
in the United States.Indeed, the definition of "abstinence
education" in the draft follows almost verbatim the eight-part definition of
"abstinence education" in the U.S. Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 cited above.The Ugandan definition, which is in seven parts, reads:

Teaches that abstinence from sexual activity is
the only certain way to avoid sexually transmitted diseases, and other
associated health problems;

Teaches that a mutually faithful monogamous
relationship in context of marriage is the expected standard of human sexual
activity;

Teaches that sexual activity outside the context
of marriage is likely to have harmful psychological and physical effects;

Teaches that bearing children out-of-wedlock is
likely to have harmful consequences for the child, the child's parents, and
society;

Teaches young people how to reject sexual
advances and how alcohol and drug use increases vulnerability to sexual
advances[60]

The U.S.
legislation from which this is drawn is not cited anywhere in the policy document.Later in the document, the AB policy is
described as follows:

Sexual abstinence until marriage and faithfulness in
marriage will be widely promoted as the most effective means of preventing STI
[sexually transmitted infections]/HIV transmission.Special emphasis will be placed on promoting
delaying sexual debut among the young and faithfulness in marriage, eliminating
sexual promiscuity.[61]

The document further calls for the establishment of an
"A&B [Abstinence and Being Faithful] Coordination Unit" (ABCU) within the
Ugandan Ministry of Health, as well as a "National A&B Policy Steering
Committee" (NABPSC) and an "A&B Coordination Committee" (ABCC).None of these proposed entities is given a
mandate beyond promoting abstinence and faithfulness.

With respect to the promotion of condoms, the AB policy is
contradictory.At several points, the
policy speaks in terms of bringing AB interventions on an "equal footing" with
existing condom interventions; it states that local AIDS programs should
"ensure that A, B and C are mutually complementary and not competitive
strategies."[62]Elsewhere, however, the policy suggests that
information about condoms can undermine the message of abstinence.Under the sections entitled "core values" and
"quality assurance," the document reads:

Messages about HIV and AIDS need not be ambiguous and
mixed up.A and B work in one sense are
[sic] a personal challenge that calls
for self-denial of immediate pleasure in favor of some good or positive
health-or even survival.The mixing of
this message with an offer of perceived immediate gratification by means of
condom use can be confusing to youth and indeed adults.The condom message can compromise the power
of the A and B message.Nevertheless,
the policy is to promote A and B without reducing the value of the C message,
just as condoms must be promoted in ways that do not undercut or undermine
messages of abstinence and faithfulness.

. . .

. . . since A&B messages work in part on the
principle of motivating people to deny current pleasure in favor of a future
good, it is possible to have the quality and strength of an A&B program
diminished by simultaneously presenting a risk reduction behavior (e.g., condom
use) as an equal and easier alternative; this is not true.Implementers can do risk reduction education
and promotion but not risk reduction adoption and sustainability.Abstinence promoters should avoid diminishing
program quality by sending out contradictory messages.[63]

The AB policy's narrow focus on abstinence and fidelity to
the exclusion of all other determinants of HIV risk is reinforced in its
section on monitoring and evaluation.Despite recognizing the link between HIV infection and practices such as
domestic violence, rape, and wife inheritance, the policy contains no
indicators on reduction of these practices.Nor does it even seek to measure whether program participants actually
adopt abstinence or fidelity as HIV prevention strategies; rather, it measures
only national trends in sexual behavior, which says little about the experience
of program participants.In addition,
the policy measures numerous process issues such as meetings and reports of AB
agencies and task forces and the preponderance of abstinence and fidelity
messages being provided in the country.By these indicators, the policy could be considered a success even if it
fails entirely to effect changes in the sexual behavior or HIV risk of
Ugandans.

Despite the fact that numerous evaluations of
abstinence-only programs have been conducted in the United
States, none of these evaluations is mentioned in Uganda's
draft AB policy.It is possible that the
authors of the draft were not aware of these studies or did not consider them
relevant to the Ugandan context; however, the Ugandan government should address
this concern.It is of the utmost
relevance that every independent evaluation to study abstinence-only programs
has found them to be ineffective at influencing participants' sexual intentions
and behavior, and possibly harmful.(These studies are reviewed later in this report.)

A further concern is that the draft AB policy does not
adequately address the high risk of HIV faced by married people, especially
women.At several points, the policy
suggests that strengthening the institutions of marriage and the family is an
effective approach to preventing "social problems" such as HIV/AIDS.The section entitled "guiding conceptual
principles/model" states:

The family institution is the cradle of civilization,
because it [is] the natural training ground for civil behavior, morals,
sexuality, integrity, interpersonal relationships essential for life, work
ethics, life skills etc.In other words
when the family institution is functioning as it was meant to function, many
social problems which ultimately feature on a national level can be eliminated,
and hence the need to pay special attention to Marriage and the family
institution.[64]

From a public health point of view, it is true that mutual
fidelity to an HIV-negative partner can help to prevent sexual transmission of
HIV.However, as the draft AB policy
recognizes in its section on "implementation modalities," women face a high
risk of HIV from such things as domestic violence, unequal gender relations,
and wife inheritance.[65]These issues should be more clearly
integrated into the document's discussion of marriage and the family.

In the section on "strategy for implementation," the draft
AB policy proposes mandatory HIV testing for married couples as a solution to
HIV transmission in marriage.The
document states:

Communication for being faithful should be integrated in
all pre-marital counseling and an HIV test should be required for all those
intending to get married.[66]

Forced HIV testing is in itself an infringement of the right
to bodily autonomy and to informed consent for medical procedures, as
recognized by national and international legal standards.[67]Making an HIV test a precondition of marriage
also infringes upon the right to marry and, especially for women, leads to the
risk of violence, discrimination, and stigma on disclosure of HIV status.While couples intending to marry should have
full access to voluntary HIV counseling and testing, this does not substitute
for legal protections against marital rape, domestic violence, wife
inheritance, and other human rights abuses that increase married women's HIV
risk.Nor does it address widespread
social approval of men's infidelity, which persists in Uganda despite longstanding efforts
to highlight the risk of HIV brought about by extra-marital sex.

Presidential
Initiative on AIDS Strategy for Communication to Youth (PIASCY)

Following the 2001 U.N. General Assembly Special Session
(UNGASS) on HIV/AIDS, President Museveni returned to Uganda with the goal of promoting
increased education about HIV prevention to children and young adults.Together with the Uganda AIDS Commission
(UAC), Museveni launched the Presidential Initiative on AIDS Strategy for
Communication to Youth (PIASCY) in 2002.To date, PIASCY has included the creation and distribution of manuals on
HIV prevention for primary school teachers, the drafting of secondary school
materials, and HIV-themed youth rallies held in various districts.

Although it preceded the launch of the U.S. global AIDS initiative (PEPFAR), PIASCY is
at the cornerstone of the U.S.
government's abstinence-until-marriage initiative in Uganda.PIASCY is funded by the U.S. government through USAID and
the Centers for Disease Control, both of which have provided technical support
to the initiative.[68]Since 2004, PIASCY has been supported mainly
by PEPFAR funds.According to an
official at USAID in Uganda,
PIASCY is an "abstinence curriculum" that seeks primarily to empower young
people to delay sex until marriage.

PIASCY
in primary schools

In 2004, two PIASCY teacher's handbooks, one for pupils in
grades Primary (P)3 and P4 and one for pupils in grades P5 to P7, were
distributed to every primary school in Uganda.Prior to the launch of PIASCY, in 1997, the
implementation of a policy of seven years of free schooling under a universal
primary education (UPE) scheme had caused net enrollment in primary schools to
increase to nearly 100 percent with a majority of primary school entrants
reaching grade five.[69]Targeted HIV/AIDS prevention messages delivered
in schools can therefore theoretically reach nearly every primary school child
in the country, at least in the early grades.Children in Uganda's
primary schools are typically aged seven to thirteen, but in many schools,
particularly in rural areas, children in upper primary school may be in their
middle or late teens.This is because
many pupils who had previously dropped out of school re-enrolled at an older
age once it became free.

PIASCY is the most recent prevention program in Uganda
to target children at the primary level.In 1986, the United Nations Children's Fund (UNICEF) and the government
of Uganda
began working to provide prevention information to pupils, starting with the
School Health Education Program (SHEP).SHEP introduced ten units of science and health education into the
primary school curriculum with an emphasis on HIV/AIDS information.In the 1990s, national examinations included
questions related to the disease.By the
middle of the decade, educators reported that pupils had sufficient knowledge
of the disease but little corresponding behavior change; thus, in 1996 Uganda
established "life skills education" (LSE) programs to supplement existing
prevention information.Life skills
education focused on empowering girls and boys to be self-confident decision
makers with the ability to delay sexual debut, negotiate safe sex, and become
responsible citizens.These programs
emphasized student participation and incorporated an HIV prevention message of
delaying sex, "zero-grazing" (reducing the number of sexual partners), and
correct and consistent use of condoms.[70]

In every primary school visited by Human Rights Watch in
November 2004, school staff members were following the PIASCY program.Officials at the Ministry of Education said
that manuals had been distributed nationwide and trainings had been provided to
at least three teachers per primary school.Every two weeks, entire schools were meant to hold assemblies with
trained teachers instructing the student body with one of twenty-six "messages"
found in the manuals.The assemblies
opened with the message, "Choose to abstain" and proceed to address numerous
aspects of HIV prevention (including messages entitled "Condom use" and "HIV
testing"), sexual and reproductive health, and "life skills" such as
self-esteem, assertiveness, and resisting peer pressure.Other abstinence-oriented messages include
"Virginity is healthy," "Choose to delay sex," "Pre-marital sex is risky," and
"Acceptable moral practices."[71]In addition to the assembly messages,
teachers were encouraged to incorporate each biweekly message periodically in
their class lessons, regardless of the subject.According to the officials, PIASCY simply reinforced existing prevention
and health messages in the science curriculum (which varied from district to
district) and supplemented this information with a national, standardized
program.[72]

Educators, health officials, and aid workers in Uganda
spoke favorably about PIASCY, particularly its ability to reach nearly every school-age
child.Some raised concerns, however,
with the content and appropriateness of the materials, the effectiveness of
messages delivered at assemblies, and the lack of emphasis on student
involvement.When presented with these
concerns, Ministry of Education officials countered that if PIASCY were
implemented correctly and further trainings and monitoring conducted, many of
these issues would be resolved.[73]

Although PIASCY was launched in 2002, the manuals for the
primary level were only distributed nationally in 2004.According to several of those involved in the
writing and editing process, initial drafts were prepared in late 2002 and
edited in 2003, and a final book, pilot-tested and approved by teachers in two
districts, was launched by the president on March 21, 2003.Around the same time, however, several groups
began actively protesting the content, focus, and messages in the books,
vocally denouncing them and delaying their national distribution.Concerns about the content of the manuals were
largely voiced by religious groups who had not been included in the initial
consultative process.[74]An individual from one of these faith-based
organizations argued that sexually explicit diagrams contained in the manuals,
such as an illustration of a penis with a condom on it, would encourage
children to start having sex.[75]According to Ministry of Education officials,
in addition to the diagrams, religious groups insisted on a separate section on
"ethics and morals" and increased information on abstinence until marriage as
an HIV/AIDS prevention strategy for youth.[76]

In late 2003, the government held additional stakeholders
meetings sponsored by the U.S.
government in order to respond to these objections.One observer said of the faith-based groups'
participation in the meetings, "Everywhere the manual said, 'There will be some
children who have sex,' they crossed it out and said, 'They should be told to
stop.'"[77]In the end, the expanded group of
stakeholders made some changes, and two books, one for upper primary and one
for middle primary, were launched in February 2004.[78]The new manuals omitted information from the
initial text, including diagrams on how to correctly clean the penis and
foreskin, how the body changes at puberty for boys, and how semen is ejaculated
during sexual intercourse.A chapter on
"ethics, morals and cultural values" was added as well as two assembly messages
on the risks of pre-marital sex and on "acceptable moral practices."The assembly message on condom use was
altered, and a diagram illustrating a condom offering protection from HIV was
removed.[79]

The withdrawal of important and potentially life-saving
material from primary school texts raises serious concerns about children's
right to complete and accurate HIV/AIDS information.In the case of PIASCY, the offending manuals
were designed as teachers' handbooks only and were not intended for
distribution to children.Moreover, many
of the controversial pictures and diagrams, including information on correct
condom use, had been presented in HIV prevention materials at the primary level
in Uganda
since the late 1980s.Asked why it was
necessary to remove explicit images from teachers' handbooks, officials at the
Ministry of Education said that some stakeholders were concerned that children
might see the images if they borrowed the books from their teachers or saw them
lying around.[80]

The inclusion of religious actors in the development of
primary school HIV/AIDS materials should not amount to a veto over
science-based health information.Individuals with considerable experience in reproductive health and sex
education in Uganda
said they were stunned by the empowerment and involvement of religious
activists in the development of PIASCY."Religious groups have never had a veto before," said one experienced
sex educator.[81]This individual noted that faith-based
organizations had historically played an important role in fighting HIV/AIDS in
Uganda, particularly in caring for people living with AIDS and providing
spiritual guidance, but had never shown much interest in prevention materials
for children."Religious groups have
never vetted materials going into schools," the observer said."Where is it going to stop?"[82]Another participant reported that some of
these groups had recently become financially empowered due to funding from
U.S.-based sources and had developed links to the highest political offices, so
their comments could not be ignored.[83]

The content and launch of the PIASCY materials for primary
schools has been significantly influenced by U.S. policy and funding in support
of abstinence-only programs.According
to one USAID employee, PIASCY is the brainchild of Uganda
but has been funded by the U.S.
from "close to the beginning."[84]An official at Uganda's
Ministry of Education told Human Rights Watch that direct U.S. involvement in the PIASCY
primary school materials began just as the initial teacher's volume had been
completed.At the same time that
religious organizations were voicing their concerns about the content of the
PIASCY materials, an employee of the USAID-funded AIDS/HIV Integrated Model
District Program (AIM) contacted the Ministry of Education and cautioned that
it would be necessary to re-work the books so that they would be acceptable to
everyone.[85]The AIM employee relayed that AIM had
considerable experience with schools in many parts of the world and that
parents rejected books that were too graphic or explicit.Following this intervention, AIM sponsored
and paid for the stakeholders' meetings that included religious groups not
involved in the initial consultative process.AIM later facilitated the publication of the two primary teachers PIASCY
volumes.In 2003, USAID also placed a
technical advisor at the Ministry of Education to coordinate the PIASCY
materials and oversee the content of the materials.[86]

In 2004 the Uganda
Program for Human and Holistic Development (UPHOLD), another USAID-funded
entity, held trainings for teachers on the PIASCY materials.Approximately 40,000 teachers in over 14,000
schools were trained nationwide, and UPHOLD continues to be involved in the
monitoring and evaluation of PIASCY.The
UPHOLD employee responsible for the trainings told Human Rights Watch that
during the trainings, teachers expressed interest in learning about correct
condom use but were instructed to teach only abstinence to children."What we are telling them is, yes, we know
the condoms are there, but at this age [primary school], we are preaching abstinence."[87]This message contradicts information supplied
in PIASCY's own Primary 5-7 manual, which states, "Pupils will definitely ask
you about condoms, and there is no reason to avoid talking about them.Used consistently and correctly, condoms
protect against HIV/STIs and pregnancy."[88]

In response to questions about the U.S. influence on the PIASCY program, members of
the U.S. government's PEPFAR
team in Uganda stated that
while PIASCY had been funded by the U.S., it was in no way an
"externally driven" process.They said
that internal groups were responsible for the changes in the content of the
teacher's manuals, and that the process was owned by the Ugandan
government."Even if we supply the
majority of funds to PIASCY, it does not mean we control it," one said.[89]It is evident from teachers and those
involved in the drafting process, however, that the U.S. government through its
implementing partners had considerable influence both on the removal of
information from the materials and the training of teachers who would
ultimately be presenting them to school children.

In all schools visited by Human Rights Watch in November
2004, PIASCY materials were being used at assemblies and in classes, but there
was considerable variation in the information provided to pupils.Educators expressed divergent views on
teaching pupils about condom use. Some said they evaluated the needs of the
students and what they had done in the past against what they had been told in
the PIASCY trainings or what they believed was politically strategic.At a primary school in Kasese district,
teachers said that the message about condoms they had been told to give in
PIASCY trainings conflicted with that found in the science curriculum.They said that they were not providing information
on condom use because according to their PIASCY trainers, parents in the
community might complain.[90]At another school in the same district,
teachers said that PIASCY's message on condoms is that "it is better to
abstain."A group of three teachers
said, "At the PIASCY training, we were told not to show [pupils] how to use
condoms and not to talk about them at our school.In the past, we used to show them to our
upper primary classes.Now we can't do
that."[91]

The headteacher at another primary school in Kasese district
said that information on correct condom use was essential for older children at
her school, as recognized in both PIASCY and science curriculum materials.She estimated that perhaps 20 percent of
girls at her school were sexually active, so it was necessary to include
information about condom use and partner reduction in addition to delaying or
stopping sex as an HIV prevention strategy.[92]

In one school in Mbale district in eastern Uganda, educators omitted any
message about condoms in the PIASCY program because, as one headmaster put it,
"President Museveni said there is no use teaching young people about condom
use, because then children will go and experiment with them."[93]The headmaster nevertheless felt that condoms
had to be discussed with his older students, because:

Some primary children are already playing sex.Some girls from the villages rent houses here
in town to attend school and are engaging in sexual relations with older
men.Boys are doing the same, going to
video shops, watching movies . . . . They are on their own and can get into
trouble.For example, we recently had a
girl from a nearby village in P4 who was having sex with a car washer in
town.She is twelve years old.[94]

In part because some of the children are sexually active,
this teacher talks about condoms outside the context of the PIASCY program.

The headteacher at another school in Mbale district said
that condom demonstrations were done at her school, but only by outside groups
who were not part of PIASCY.She said,
"The point of PIASCY is that these kids are too young for sex.In our assemblies and in the classroom, we
explain what abstinence is and why it is important . . . . But around here,
people don't buy this idea of abstinence because in Uganda, many girls are using sex to
buy their daily bread."[95]

Representatives of nongovernmental organizations
specializing in education and HIV prevention raised concerns that PIASCY
promoted marriage as an HIV prevention strategy.To their credit, the PIASCY teachers' manuals
contain clear messages that marriage does not provide automatic protection
against HIV.Other sections of the
books, however, promote marriage as an ideal.They list sexual expression in marriage as a way to "avoid the sin of
sexual immorality" and "protect society from sexual disease."[96]This creates the risk that teachers will feel
more comfortable presenting marriage as a prevention strategy than providing
more detailed and frank explanations of the risk of HIV faced by married
people, particularly married women.One
teacher at a primary school in Mbale said that in PIASCY, "We talk about
marriage, what it is, when one should marry and how to be good in
marriage."This same teacher, when asked
about using condoms either within or outside of marriage, said, "We discourage
condom use.They can burst, and some can
acquire STDs [sexually transmitted diseases] or become pregnant while using
them.Condoms encourage pupils to keep
practicing sexual behaviors."[97]

Young people in Uganda have a right to accurate
information that is based on scientific fact.Marriage does not "protect society from sexual disease" as stated in
PIASCY, nor should it be presented as a reliable HIV protection strategy.Pupils have a right to know that inside and
outside of marriage they face the risk of HIV and STIs, and that in Uganda,
as in many countries, many men and women have contracted HIV and other sexually
transmitted diseases from their spouses.The view expressed by many people involved in PIASCY that information
about condoms encourages early sexual behavior is also inaccurate and should
not be used as the basis for denying young people information that could save
their lives.

Not only the content of PIASCY messages, but also the form
in which they are delivered, suggested they were geared more toward preaching
"good behavior" than toward preventing HIV and unwanted pregnancy.As noted above, PIASCY messages are delivered
to students primarily at assemblies held at the beginning or end of the school
day.Students gather outside the
classroom, and teachers read aloud one of the messages contained in the
teachers' handbooks.Schools hold
assemblies at least once every two weeks, with some schools gathering students
for PIASCY messages several times a week.Teachers with considerable primary school experience raised the concern
that messages delivered at school-wide assemblies were unlikely to achieve
lasting behavior change among youth.In
the 1990s, education specialists had remarked that HIV prevention information
provided to children in Uganda
did not bring about expected behavior change, so the emphasis was adjusted to
highlight child participation in group settings.With PIASCY, this adjustment was
reversed.Some teachers raised fears
that dictating message at assemblies revived pedagogical approaches already
proven ineffective in the early 1990s.

PIASCY requires that messages delivered at assemblies be
reinforced in the classroom through the inclusion of examples into daily
lessons.In addition, the handbooks
provide many suggestions to teachers for activities both inside and outside the
classroom.Teachers said that the
emphasis on holding assemblies, while publicly visible and easy to monitor,
left little time for additional activities that would reinforce behavior change,
such as student in-class involvement or group role-play.A teacher at a rural primary school said that
PIASCY had come with no materials to assist with demonstrations or activities.When teaching girls how to manage
menstruation, for example, she had to bring in her own cloth (for use as a
menstrual pad) for the demonstration.Another teacher remarked that PIASCY activities were a good idea in
theory, but that her school lacked materials for additional projects.[98]

To these concerns, Ministry of Education officials countered
that the program was just beginning and that it would evolve over time.They explained that PIASCY should not be seen
as a "top down," dictated approach, but rather that through teachers' interpretation
of the messages in the classroom, parent and community members' involvement and
children's activities, the program would foster dialogue and communication and
empower boys and girls to protect themselves.[99]

PIASCY
in secondary schools

At this writing, the Ugandan government is expanding PIASCY
to secondary schools with the publication of handbooks for both students and
teachers.Two books have been drafted
and are in the editing process.Unlike
at the primary level, the dissemination of PIASCY messages in secondary schools
is to be done in the classroom and not at an assembly.Various suggestions have been put forward
that PIASCY be incorporated into existing classes such as Christian Religious
Education or Biology, and/or included sporadically throughout lesson plans in a
number of subjects.

Partners involved in the editing of PIASCY secondary school
materials told Human Rights Watch that factual information about masturbation,
abortion, and homosexuality was at risk of being omitted because of vocal
opposition against their inclusion by powerful groups.Much as was the case in the primary
materials, information on condoms, family planning, and
abstinence-until-marriage is also contested.Participants interviewed for this report said that some individuals or
faith-based organizations who advocate abstinence-until-marriage and
anti-condom positions are financed through U.S. churches and anticipated
future funding through PEPFAR.They
suggested that these links to outside sources explained their recent
empowerment.In addition, they accused
these groups of promoting abstinence not because it is a sound prevention
strategy, but because this is the approach favored by both the U.S. government
and U.S. fundamentalist churches that are fueling the growth of a Ugandan
fundamentalist revival and more importantly, because funding is now being made
available to Ugandan groups who promote abstinence.[100]

Draft copies of PIASCY secondary school materials obtained
by Human Rights Watch contain incorrect and misleading statements that, if finalized,
would infringe children's right to accurate information about HIV
prevention.For example, the draft texts
for both students and teachers state that "condoms are not 100% perfect
protective gear against STDs and HIV infection.This is because condoms have small pores that could still allow the
virus through."[101]In fact, laboratory tests show that neither
HIV nor any STD pathogen can penetrate a correctly used latex condom of
standard acceptable quality, and that using a latex condom to prevent HIV has
been estimated to be 10,000 times safer than not using a condom.[102]These same drafts state, "Some statistics
indicate that condoms have a less than 65% protection rate implying that
reliance on them could mislead many youth into risky 'unsafe' sex."[103]Beyond failing to cite where these statistics
can be found, the drafts do not mention that epidemiological studies have shown
that consistent condom users are in fact 80-90 percent less likely to become
infected with HIV from sexual intercourse than non-users.[104]The books then instruct teachers that the
best approach to sex and HIV/AIDS education is to show students the
inefficiency of condoms, to demonstrate the "loopholes" of the condom, and to
debate the benefits of abstinence.[105]

The handbooks later encourage children, when they reach
adulthood, to use condoms in marriage to prevent unwanted pregnancies and
HIV/AIDS.They even guide teachers to
correctly demonstrate condom use in the classroom.These messages, however, do not explain why
condoms are encouraged for married adults as useful in HIV control but unsafe
for unmarried adults or adolescents.Nor
do they explain why "small pores that could still allow the virus through" do
not affect married couples.[106]

Another troubling aspect of the drafts is their emphasis on
marriage as an institution that provides a measure of protection against
HIV.In Chapter Three, students are
advised "to abstain from sex altogether until they are mature enough to get
married.Sex before marriage is not only
breaking school rules, but against religion and norms of all cultures in Uganda,
and having pre-marital sex is considered a form of deviance or misconduct by
the persons involved."[107]In Chapter Eight, under advice on the best
approaches to sex and HIV/AIDS education, teachers are recommended to tell
students to wait until marriage and to use marriage teachings to encourage
youth to wait.[108]The texts contain no information on the
number of Ugandans, especially women, who remain faithful until and during
marriage only to contract HIV from their spouses. There is no explanation as to why many
Ugandans in their twenties test positive for HIV, by which time many are
already married.[109]

Secondary school students and teachers interviewed for this
report agreed that more HIV/AIDS information provided at school through a
PIASCY program would be beneficial, but only if that information were relevant
to their life experience.One history
teacher told Human Rights Watch that students at his school were interested in
learning how to use condoms correctly because some said they don't know how.[110]A seventeen-year-old student said:

Some young people are sexually active when they reach
secondary school.Many of my friends at
school are having sex.The condom
information provided at [after-school HIV] clubs is useful because you might
feel you want or are ready to play sex.And when you are ready, you now know why and how to use a condom.[111]

An HIV/AIDS training officer who holds meetings at secondary
school clubs illustrated why providing information on correct condom use to
youth was necessary.At one school she
visited, a government-funded religious school, the headmaster refused to allow
information on condoms to be presented in the belief that it would promote
sex.After watching the trainer's
presentation and the many questions from students about condoms, sexual
relations, and HIV prevention, however, the headmaster agreed that providing
correct information on condom use was necessary for the safety of the
students.For this trainer, delaying
sexual debut was an important prevention message that young people needed to
hear, but it should not trump other equally important information.[112]

According to teachers and students in secondary schools
visited by Human Rights Watch, some HIV/AIDS and sexual reproduction
information was already provided in both biology class and a class entitled
Christian Religious Education (CRE).A
religious education teacher said that he emphasized abstinence and the Bible
when discussing sex and HIV.He taught
children to fear God and to avoid sex in order to remain safe.[113]Students who had enrolled in CRE said that
the focus rested on marriage as "God's gift" and on the "sin" of premarital and
same-sex relations.HIV was presented as
a curse on immoral people who engage in sex.[114]As noted above, one proposal for integration
of PIASCY at the secondary level is in CRE class.[115]

Abstinence
programs out of school (including after-school programs)

A third part of the PIASCY initiative is to target children
and young adults who are not receiving HIV/AIDS information in the
classroom.In coordination with the
Uganda AIDS Commission, the office of the president conducts youth rallies in
districts around the country with the aim of training youth leaders in HIV/AIDS
awareness.An official in the office of
the president told Human Rights Watch that as of November 2004, seven rallies
had been held throughout the country and eight more were planned.Rallies are held at schools that can
accommodate large numbers of participants during school holidays.Youth leaders, out-of-school youth and
students aged fifteen to thirty are invited to attend.Roughly one thousand participants are
invited, but as many as 2000 youth have attended.Speakers at the rallies have included
officials from relevant ministries, politicians, military officers, health care
officials, religious leaders, and the president of Uganda.[116]

In interviews with Human Rights Watch, long-time AIDS
activists supported the targeting of out-of-school children and youth leaders
in rural districts as a way of further educating young people on HIV
prevention.But they questioned the
applicability of the information provided at the rallies, with its emphasis on abstinence
and its denigration of condoms-particularly as participants were largely men
and women in their twenties who were already sexually active.They equally raised concerns about the
apparent blending of politics and HIV prevention in a way that may alienate
those who do not support the president.[117]

A United Nations official familiar with the rallies said
that the HIV prevention messages were little more than window dressing for
delivering political messages to rural areas in support for Museveni's bid for
a third-term in office.[118]An AIDS activist in Kampala said:

PIASCY rallies appear to be promoting an ideology as much
as providing HIV/AIDS information.The
attendees and participants are clearly those interested in promoting a third
term, not really youth leaders from the full spectrum of society.I feel that the goal of PIASCY is very
good.The problem is that it tends to be
associated with the personality of the president.When this happens, it fails to be educational
materials, but increasingly, [is] perceived as a political tool.[119]

This sentiment was echoed by numerous others.An official in the office of the president
told Human Rights Watch that the rallies sought to provide information to young
leaders about HIV/AIDS and development.But, she said, various officials from the government were available "to
take questions about our government from the young people."She added:

We talk about the political transition, what is the
process.Young people have grown up in
the movement system.[120]They need to understand what is happening
now, they need to understand about the third term.So, they are very enthusiastic to learn about
the NRM-O [National Resistance Movement Organization] and the plans for the
future.[121]

At one rally held in Arua in October 2004, during a session
linking HIV/AIDS and good governance, the speaker stressed the achievements of
the Movement system in fighting HIV/AIDS and warned that should there be a
change in government, there may be an escalation of Uganda's AIDS epidemic.[122]Youth were informed that the president's
pursuit of a third term stemmed from popular demand.According to a summation of discussions held
among young people at the rally, youth in attendance recommended, "The youth of
West Nile Region join other citizens of Uganda in calling foran open term
limit for the Office of the President."[123]

At the same rally, various speakers informed participants
that "condoms are becoming extremely unsafe, that is why emphasis is shifting
to Abstaining and Be Faithful," and "using a condom with a person with these
[sexually transmitted] diseases is like using a parachute which opens only 75%
of the time."[124]Participants were also told that "sex should
only be in marriage," and that "there is an 80% chance of death during labour
if one conceives below the age of 18."[125]

As with other PIASCY programs, providing misleading
information on the efficacy of condoms, promoting marriage as a foolproof HIV
prevention strategy, and proving false information on maternal mortality denies
young Ugandans their human right to accurate health information.Equally troubling is the apparent political
motive of these rallies and their promotion of the movement system and the
president's strategy for a third term in office.Ugandans have a right to choose their
president and govern their country as they deem appropriate, but partisan
political campaigning is not an appropriate use of public HIV/AIDS funding from
Uganda's or any other country's treasury, quite apart from its lack of public
health value.In at least some districts
and in the case reported above on Arua, PIASCY rallies are financially
supported by the U.S.
government through its implementing partners in Uganda.[126]

The use of U.S.
government funds, even inadvertently, to promote the political aspirations of a
party or personality do not fall under the stated goals of PEPFAR to "promote
integrated [HIV] prevention, treatment and care programs."[127]PEPFAR funding for HIV prevention programs
should neither be associated with politics nor used to further any purpose
beyond the provision of effective information and services to the largest
number of recipients possible.

Faith-based
organizations promoting abstinence

Aside from programs provided under PIASCY, a number of
nongovernmental and faith-based organizations in Uganda
are increasingly receiving support from the U.S. and Ugandan governments to
promote abstinence to youth.Many of
these faith-based organizations are represented by individuals or churches
linked to fundamentalism, a rapidly growing brand of Christianity in Uganda
particularly attractive among young people.Approximately 60 percent of Ugandans are Christian; while the Catholic
church the largest denomination, it has been estimated that 25 percent of
Ugandans identify with fundamentalist churches.[128]The U.S. global AIDS strategy notes
that "faith-based and community-based groups . . . have established excellent
prevention programs in the [area] of abstinence promotion" and that "FBOs
[faith-based organizations] are in a strong position to help young people see the
benefits of abstinence until marriage and support them in choosing to postpone
sexual activity."[129]In December 2002, U.S. President George W.
Bush issued an executive order establishing a Center for Faith-Based and
Community Initiatives at the U.S. Agency for International Development, the
purpose of which was to remove any obstacles to community and faith-based
organizations' participation in USAID programs and promote their involvement
"to the greatest extent possible."[130]A USAID-funded HIV/AIDS organization in Uganda
told Human Rights Watch that in their application to USAID for PEPFAR funds,
they were required to state how much money that they would sub-grant to local
faith-based organizations.[131]

Uganda Youth Forum

Perhaps the best known abstinence advocate in Uganda
is Janet Museveni, the wife of President Museveni.Mrs. Museveni has been an outspoken advocate
for virginity for many years and has described abstinence as the perfect
blending of Christian teachings and traditional African values.In 1991 Mrs. Museveni founded the National
Youth Forum, an organization whose principal activity is to organize retreats
in which boys and girls sign commitment cards to remain "sexually pure" until
their marriage day.According to the
Youth Forum, more than 70,000 youth have signed these cards since 1992.[132]

Coupled with Mrs. Museveni's pro-abstinence stance is her
anti-condom advocacy.On numerous
occasions, the first lady has publicly lashed out against organizations that
support condom use for young people, arguing that these organizations promote
sex among children.She has claimed that
condoms are not safe in preventing HIV and STIs and that she supports an
exclusive message of abstinence and faithfulness for Ugandans.As an HIV prevention strategy, she has called
for a national census to determine the percentage of children and young adults
who are virgins, the percentage who have practiced "secondary abstinence"
(abstinence among those who have already been sexually active), and the
percentage that are sexually active.[133]

Uganda
already collects national data on sexual behavior through its periodic
U.S.-funded demographic and health surveys.Mrs. Museveni's extraordinary call for a national "virgin census" raises
legitimate fears that young people will be pressured into disclosing
confidential information about their sexual lives or, worse, that they will be
forced to submit to intrusive medical examinations of their virginity
status.From a human rights point of
view, virginity testing constitutes an infringement of the right to privacy, a
form of gender discrimination when practiced predominantly among girls, and a
violation of the right to bodily integrity.[134]

Among the many criticisms of abstinence programs is that
young people who "fail" to abstain will not be equipped with the information
and tools they need to prevent HIV, other STIs and unwanted pregnancy.A young woman who had attended a National
Youth Forum event in the mid-1990s told Human Rights Watch that some of her
peers who signed commitment cards were already sexually active.As she put it:

There is real difference between the aims of the
organizers [of the Youth Forum] and the aims of the youth who attend.We would go to meet boys there. Our parents
were strict. This [the Youth Forum] was a legitimate excuse to get out of the
house and socialize with members of the opposite sex . . . . While there are
some who remain virgins until they are married, I did not and neither did my
friends."[135]

Further, U.S.
surveys suggest that young people who commit to virginity until marriage may be
at higher risk of HIV than others because they are less likely to use condoms
when they begin having sex or to get tested for STDs.[136]

According to a representative of the first lady's office,
the Youth Forum is funded by foreign donors, and that "because of the Bush
Administration's support for abstinence, it has helped us a lot."[137]An article published in World magazine in November 2004 alleged that Mrs. Museveni had
received U.S.$3 million from the U.S. government to promote her
abstinence and faithfulness programs.[138]Several U.S.-based nongovernmental
organizations operating in Kampala
also reported that the Youth Forum had been funded with PEPFAR HIV prevention
money.[139]Human Rights Watch was able to determine that
at least one USAID-funded organization in Uganda
was sub-contracting the Youth Forum and that, with U.S. government support, the Youth
Forum was developing abstinence materials to be distributed nationally.[140]In November 2004 the U.S. Office of the
Global AIDS Coordinator approved a PEPFAR-funded abstinence-until-marriage
grant to the Children's AIDS Fund (CAF), a Virginia-based organization with
close ties and an intention to sub-grant to the Youth Forum, despite the fact
that a technical review panel had found CAF "non-suitable" for such a grant.[141]Providing U.S. HIV/AIDS funds to the National
Youth Forum-an organization that engages in religious proselytizing and
conducts HIV prevention rallies with an explicitly Christian
message-constitutes a possible violation of U.S. law.[142]The organization's promotion of virgin
censuses, in particular, raises serious health and human rights concerns.

MakerereCommunityChurch

Another leading advocate of abstinence-only programs in Uganda and an author of the Uganda AIDS
Commission's draft "AB" policy is the founder and pastor of MakerereCommunityChurch, Martin
Ssempa.Known for his charismatic brand
of fundamentalist Christianity, Pastor Ssempa has, on various occasions, spoken
out against homosexuality, condoms, Islam, and women's human rights.The community church's student drop-in center
on the campus of MakerereUniversity, known as the
White House, provides counseling, meetings, musical entertainment, and a
"deliverance room" where students ostensibly possessed by Satan can "exorcise
their demons."[143]

Speaking at an abstinence rally in December 2004, Pastor
Ssempa reportedly stated, "We are promoting abstinence because Uganda
is under attack from an agenda driven by homosexuals and Western experts."[144]Ssempa has compared his fight against the
Islamic faith in Uganda to
the United States' invasion
of Iraq.[145]In late 2004, he called for re-baptizing the
vice-President of Uganda
whom he alleged to have made a covenant with a witchdoctor.[146]

Human Rights Watch researchers made repeated requests to
meet with Pastor Ssempa to discuss his HIV prevention programs for youth, but
he said he was not available to meet with us.We did, however, visit the "White House" and speak with several staff
members.According to the staff members,
HIV prevention programs promoted by Ssempa promoted abstinence-until-marriage
and a return to God's values; they opposed condom use, sex outside marriage,
homosexuality, and abortion.The mission
of the church, they said, was to train youth at elite universities today to
replace leaders in secular governments with Christian fundamentalists.Staff members said that Ssempa received
considerable financial support from U.S.-based churches and American
evangelicals.In the week preceding the U.S.
election in November 2004, members of Ssempa's church reportedly were required
to fast and pray for the victory of George W. Bush.Staff members told Human Rights Watch that
this was because Bush had a similar philosophy to their church and, more
importantly, because they had been told by a prominent U.S.-based advocate for
abstinence programs in Uganda
that Bush's re-election would guarantee them PEPFAR money for their prevention
work with youth.[147]In part because Pastor Ssempa would not meet
with us, Human Rights Watch was unable to substantiate claims of alleged PEPFAR
funding to the MakerereCommunityChurch.

Family
Life Network

The Family Life Network is a private non-profit organization
that since 2002 has provided "values-based" sex education to some 130,000
students in 400 Ugandan schools.One of
the main activities of the Network is to encourage students to sign "True Love
Waits" cards, in which they pledge abstinence until marriage.Since the network began working in secondary
schools in 2002, 72,000 students have signed these cards.

In an interview with Human Rights Watch, the executive
director of the Family Life Network, Stephen Langa, stated that the four goals
of the Network were to "bring back faith in the marriage institution," to "show
the dangers of sexual involvement," to "warn children on the dangers of
globalization, such as pornography," and to "ask children to make a commitment
to abstinence."These interventions,
Langa said, were rooted in the notion that AIDS is a "moral disease" and that
"as long as we use technological means to treat moral issues, we will lose many
lives."[148]The Network's goal was "not just to prevent
HIV," Langa said, but "to have responsible citizens.People who know hard work, people who plan.People who are going to make good marriages
and good families."

Human Rights Watch asked Langa if he was aware of studies
showing that students who pledged abstinence-until-marriage often broke their
pledges and, in so doing, were often less likely to use condoms to prevent
STDs."I'm not familiar with these
studies," he said."I can't say there's
no failure, there must be some."He added
that personal testimonies he had heard from students suggested that they took
their pledges seriously and felt badly if they broke them.Asked his position on the effectiveness of
condoms against HIV, he replied inaccurately, "The failure rate of condoms used
against HIV is 20 percent."He then
presented a diagram comparing various cell sizes, including HIV, and argued
that HIV was small enough to permeate microscopic pores in latex.His main point was that abstinence is the
only 100 percent effective method against HIV."When you get involved in sex with someone who is not your wife or your
husband, you are stepping into a danger zone," he said."You are driving on the wrong side of the
road.It's just a question of when, not
if, you're going to have an accident."

Asked how his organization advised gay and lesbian youth who
could not legally marry, Langa responded that the Network did not condemn those
who were victims of "vices" such as homosexuality, but that the organization
would help them change if they were willing."If they can't get married, let them abstain," he concluded.[149]

The Family Life Network is funded by both local and foreign
donors, as well as individuals.According to Langa, the Network received 76 million Ugandan shillings
(U.S.$38,000) from the Geneva-based Global Fund to Fight AIDS, Tuberculosis and
Malaria to provide educational and behavior change activities.The Global Fund is a multilateral
public-private partnership that takes contributions from wealthy nations and
channels them through government-led "country coordinating mechanisms" in
recipient countries such as Uganda.The Network has reportedly received no money
from the United States
through PEPFAR but, according to Langa, are "exploring possibilities to receive
funding from the U.S."[150]Langa is also an author of the Uganda AIDS
Commission's draft "AB" policy.

VI.
Especially Vulnerable Persons

In order to investigate the impact of abstinence-only
programs on young people's right to information, Human Rights Watch interviewed
a wide range of young Ugandans about their sexual attitudes, intentions, and
behaviors, as well as their knowledge about HIV/AIDS prevention.Interviewees included boys and girls, both in
and out of school; children orphaned by AIDS; young people affected by war and
civil conflict; and young men having sex with men.These interviews revealed that for many
segments of the Ugandan population, including some of those at highest risk of
HIV, promoting abstinence to the exclusion of other messages violated their
right to information and to protect themselves from a deadly disease.[151]

Sexually
active young people

Despite numerous claims by proponents of abstinence-only
programs that young Ugandans are increasingly "choosing to abstain," sexual
activity among young Ugandans has in fact increased since the mid-1990s.[152]In 2000, 27 percent of single Ugandan girls
aged fifteen to twenty-four reported having sex in the past year, compared to
22 percent in 1995.While the percentage
decreased slightly among boys (from 33 percent to 31 percent), an increasing
percentage of sexually active young men are reporting non-regular partnerships
(from 55 percent in 1995 to 59 percent in 2000).Close to one-third of young sexually active
Ugandan men reported having two or more sexual partners in 2000.

As noted above, Ugandan girls who are married or in other
committed relationships are not safe from HIV.Girls typically marry men who are much older than they are, and who have
been sexually active for a long period of time.In some cases, their husbands are already married and are moving on to
their second or third wife.Even in non-polygynous
marriages, extra-marital sex is much more common among men than among women;
some 12 percent of married Ugandan men reported extra-marital sex in 2000,
compared to 3 percent of women.[153]Absent significant changes in the sexual
behavior of men, therefore, HIV prevention messages that encourage young women
(and men) exclusively to "abstain until marriage" provide a false sense of
security.

The experience of Mary A., twenty-four, illustrates many of
these points.Mary A. told Human Rights
Watch that she met her first husband when she was sixteen, and that she entered
a polygynous marriage without perceiving that she was at risk of HIV.

When I was sixteen, I met my first boyfriend.He was married.He promised me I could be his second wife, and
I accepted.After my studies, I went and
stayed with him.We had a baby boy, and
he [the baby] died when he was one.At
the time, I didn't even imagine having a son who could die of AIDS.Then, the following January, AIDS killed my
husband.[154]

Mary A. said that as a student, she was taught to abstain
until marriage:

We used to go for seminars on HIV/AIDS in vocational
school.They tried to tell us what HIV
is, how someone can get it, and how someone can avoid it.The message was, abstain from sex, and if
not, have protected sex and be faithful.But with my first husband, I asked if he had any tests.I said, are you sure you're
HIV-negative?I trusted him.I'm sure I got it from him.

Insisting that her husband take an HIV test may have helped
Mary A. avoid infection.But testing is
not a complete solution, particularly for women who marry men who are
unfaithful or have multiple wives.HIV
prevention programs need to be forthright with young women about the risk of
HIV in marriage, and also target sexually active young men-both married and
unmarried-with information and condoms so that they will be less likely to
transmit HIV to their wives.

Some argue that encouraging men to abstain until marriage
would help people like Mary A. avoid HIV infection.But both quantitative and qualitative data
suggest this strategy by itself would not be enough.As noted above, close to one third of single
Ugandan men reported being sexually active in 2000, roughly the same percentage
as in 1995.Of these, close to one-third
reported having two or more partners.Like girls, boys can be driven by situations of extreme poverty into
having sex with older partners who promise money and gifts in return.Fortunately, condom use among sexually active
young men rose significantly in the late 1990s, with 62 percent in 2000
reporting they used a condom the last time they had sex with a non-regular
partner compared to 40 percent in 1995.In this context, it is difficult to comprehend the current Ugandan
strategy of not promoting condom use to young single males.

James K., seventeen, told Human Rights Watch he began living
on the street when he was fifteen, shortly after his parents died of AIDS.Soon after, he met a "sugar mommy" who gave
him a place to stay in exchange for sex and other favors.

I had a sugar mommy, she was thirty-two.She found me in the street.I know how to drive, so I used to drive for
her.After a while, she began taking me
to her place and making me her lover.She spent three and a half months with me.I didn't like staying with her and having sex
with her, but I had nowhere else to go.She was acting as my guardian.[155]

James K. said he always used condoms with his "sugar mommy"
because, as he put it, "I'd gone to a seminar before, and they said whenever
you have a woman you should use condoms."He said he has been tested for HIV seven times and is HIV-negative.

Peer educators interviewed by Human Rights Watch underscored
the inadequacy, as well as the potential harms, of targeting young people with
strict abstinence messages and denying them information about safer sex
options.Moses T., nineteen, put it this
way:

Abstinence is a good thing, but at times this message is
too late for most of the groups we work with.Even for the "good" kids in school, many have strict parents and are not
allowed to have boyfriends and girlfriends.So any chance they get, they sneak away and have sex with whomever.This is driving the problem.Abstinence until marriage can be possible,
but only for a few.[156]

A social worker at a youth drop-in center in the Kawempe
Division of Kampala told Human Rights Watch, "Each group we work with needs its
own message. . . . Some ages and some groups will not listen to abstinence, and
we need to accept that as reality and work with them."[157]A nurse in the same center added, "The condom
message is working.We see the number
[of condoms] being used and demanded has grown, plus we've seen a reduction in
the number of STIs here at the center."[158]

Providers of youth-friendly services added that judgmental
attitudes toward premarital sex dissuaded young people, especially girls, from
seeking health services and information.Abstinence-only messages, linking pre-marital sex with immorality, are
only likely to make things worse."The
girls are involved in sex when they are young, so when they go to health
centers they get judged a lot," said the social worker cited above."So they don't go, and it's easier for men to
deceive them because they lack information."

Orphans
and children affected by AIDS

Uganda
is home to nearly one million children orphaned by HIV/AIDS in addition to
children whose parents are sick and dying from the disease.[159]While some are taken in by relatives who care
for them, others suffer abuse at the hands of their caretakers or are forced to
establish child-headed households.Still
others end up on the street, where they may engage in hazardous labor,
including sex work, to survive.Without
parental support or family income, orphans may be withdrawn from school and
forced into severe economic hardship.Many of these abuses increase vulnerability to HIV infection.Children orphaned by AIDS may be more
vulnerable to abuse and eventual HIV infection because of AIDS-related stigma
and discrimination.

A recent global report on children orphaned by AIDS produced
jointly by UNAIDS, UNICEF, and USAID concludes, "Because sexual activity (as
well as substance abuse and other risky behavior) often begins during
adolescence, it is critical to provide comprehensive sexual health education
and services to reduce the risks-often heightened for orphans-of unwanted
pregnancies, coerced sex, exploitation in commercial sex, and transmission of
sexually transmitted infections. Programs must provide information on health
behaviors and the life skills that adolescents need to protect themselves."[160]

Groups working with orphans and children affected by AIDS in
Uganda
told Human Rights Watch that abstinence-until-marriage messages were both
irrelevant and potentially dangerous.One youth activist working in the Kawempe neighborhood of Kampala said:

I wish those who preach abstinence would come down to the
slums and see how people are living.Abstinence is a message for the elite; it has no place in the
slums.These girls [orphans] live five
to a room.There is no supper for
them.The man outside says he will get
her money and a place to sleep.Now,
what is she going to do, abstain?These
orphans need assistance, services, and access to protection, not judgmental
messages.Better to be delivering
services than abstinence messages.Around here, they are a waste of time and money.[161]

A member of an outreach team organized by the AIDSInformationCenter (AIC) in Mbale explained that
messages promoting abstinence and delayed sexual debut were commonplace in Uganda,
but they had little resonance with the communities in which the team
worked.Few orphans had the choice of
abstaining from sex, he said, as poverty and hunger routinely drove them to
engage in paid sex.[162]

A seventeen-year-old orphan living in the Namatala
neighborhood outside Mbale echoed this view, saying:

For those girls who don't have parents, many are involved
in sex work.These are girls fourteen
and up.These girls don't go to school,
they lack fees.Some have good
intentions.They raise money to go to
school by selling sex.But after a
while, because they are hanging out at night in bars, they lose interest in
school and drop out.[163]

Human Rights Watch met Simon K., a seventeen-year-old boy
who had lost both his parents to AIDS, at a youth club in Kabarole
district.Simon K. was in P7 (primary
school grade seven) when his parents died, but he left school to care for two
brothers and three sisters."I would
look around for an extra banana in a plantation and try to sell it to pay for
their schooling," he said.[164]A sister and brother subsequently died, and
when we met him he was caring for his two surviving sisters, aged fifteen and
eighteen.With no income and little to
eat, he said one of his sisters was trading sex for money and food.

She slept with an older man and was given money for
it.It was last year.She was looking for a job and found work as a
house girl.After she left, her boss
followed her and offered her money to have sex with him. . . . He would pay her
about 10,000 shillings (U.S. $5.80), I don't know exactly how much.She bought knickers and a bra with it, and
with the rest she just bought something to eat.

Simon K. said he talked to his elder sister about the
importance of abstinence, but to no avail."I feel she should at least try to wait for some time in the future to
have sex, but not now," he said."I told
her that, and she says she can't do anything about it, it's the only way she
can make money.If I were able to care
for her needs, I would. But there is nothing else I can do."[165]

Refugees,
internally displaced persons, and children affected by conflict

Ongoing conflict in the north of Uganda between government forces
and the Lord's Resistance Army (LRA) has forced an estimated 1.6 million
civilians to live in internally displaced persons (IDP) camps.Commenting in November 2003 on the plight of
these civilians, Jan Egeland, the U.N. Under Secretary General for Humanitarian
Affairs, called the situation in the north of Uganda the biggest forgotten
humanitarian emergency in the world today.[166]Children, together with adults, live in
closely confined, overcrowded camps with limited access to food, water,
schooling, and economic opportunity.The displacement, poverty, and lack of employment options drive women
and girls to engage in paid sex with camp residents, local defense personnel,
and Ugandan government soldiers.While
this context makes it difficult to provide any information to those at risk of
HIV, abstinence-only approaches make it particularly difficult for those
affected to protect themselves from it.

According to one IDP camp leader, while there are cases of
rape and sexual assault in the camps, much more common is "survival sex" or sex
involving girls or young women in exchange for food or money.[167]Soldiers, who spend considerable time away
from their families at isolated posts in the camps and in positions of
affluence compared to the destitute people they protect, pay women and girls
for sex.One NGO worker said that
soldiers sometimes "will pay boys a little money, so that they will lure the
women and girls to the army installations.They will later get a little money or food for their services."[168]

LRA attacks on villages and homesteads outside major towns
in the north have led parents to send their children to urban centers at night
to avoid abduction.Parents stay at home
to guard their property while children, who are particularly targeted by the
LRA for forcible recruitment into military service, are sent off near sundown
and return home at sunrise.These "night
commuters," as the children are commonly known, spend evenings largely
unsupervised and face a high risk of sexual exploitation and assault in
addition to engaging in sex with other children.Human Rights Watch has documented cases of
rape of night commuters traveling to and from towns as well as in places where
they sleep.[169]More common is the phenomenon of girls
engaging in survival sex with civilians and soldiers and, according to one
municipal official, boys and girls engaging in drinking, drugs, and sexual
activities with one another.[170]

Sexual coercion and exploitation in the context of this
conflict is likely responsible for higher HIV prevalence rates in northern Uganda
than in the rest of the country.An
antenatal testing program for mothers at LacorHospital
in Gulu found that of those who volunteered to be tested, 11.9 percent tested
positive for HIV in 2002 compared to a national prevalence rate of just over 6
percent.[171]In Kitgum and Pader, testing programs at
three hospitals found that HIV prevalence ranged from 4.8 to 10.4 percent among
pregnant women between May and December 2002.[172]

The increased risk of sexual violence, sexual exploitation,
and heightened sexual activity among boys and girls require a realistic HIV
prevention strategy.Preliminary results
from a survey done on HIV awareness and service provisions for internally
displaced persons found a large amount of early sexual activity among
adolescent children; lower HIV awareness than in the rest of the country; and
limited access to health services.The
survey also showed that that vast majority of respondents felt that "abstinence
until marriage" was an inappropriate strategy and had no relevance to their
lives.[173]

Children also face a heightened risk of HIV infection in the
post-conflict districts of Bundibugyo, Kasese, and Kabarole in western Uganda where
the government battled the Allied Democratic Forces until 2001.Estimated HIV prevalence rates in some of
these areas are as high as 20 percent, three times higher than the national
average.[174]Youth leaders in Kasese told Human Rights
Watch that conflict in that region had displaced tens of thousands of
civilians, increased the number of orphans and street children, and contributed
to lower ages of sexual debut and marriage among children.As in the north, poverty in these rural
districts was exacerbated by the fighting and led more girls to engage in
survival sex and prostitution.[175]The leader of a youth network in Kabarole and
Bundibugyo told Human Rights Watch:

We don't think abstinence is really working in our
communities.These kids are having
sex.We work with children in primary
five through seven who are engaging in sexual activities.We always come with the message to delay
sexual debut but for most children here, this is not enough.[176]

The end of the conflict in 2001 combined with a policy of
universal primary education, has resulted in an increasing number of children
in western Uganda
returning to finish primary school.Some
of these boys and girls are in their mid to late teens and are already sexually
active; some are married and have children of their own.According to youth outreach activists working
in the schools, these older children were in particular need of appropriate
information on how to protect themselves from HIV, not messages that promote
abstinence-until-marriage.[177]

Discrimination based on sexual orientation

By definition, abstinence-until-marriage programs
discriminate on the basis of sexual orientation.For young people who are lesbian, gay,
bisexual, or transgender (LGBT)[178] and
cannot legally marry in Uganda
(as in most jurisdictions worldwide), these messages imply, wrongly, that there
is no safe way for them to have sex.They deny these people information that could save their lives.They also convey a message about the
intrinsic wrongfulness of homosexual conduct that reinforces existing social
stigma and prejudice to potentially devastating effect.

Such stigma and prejudice in Uganda exist not only in the
abstract, but are embodied in laws that criminalize same-sex sexual
relations.Political and religious
leaders as well as the media in Uganda
help to create a climate in which the legal threat of imprisonment contributes
to an environment of hatred and exclusion.[179]In 1998, for example, President Museveni told
a press conference, "When I was a in America, some time ago, I saw a
rally of 300,000 homosexuals.If you
have a rally of 20 homosexuals here, I would disperse it."[180]His minister of gender, labour, and social
development, Janet Mukwaya, later warned, "The West is bringing up
homosexuality and lesbianism under a different name, called sexual orientation
... These people want their ideas to be focused in every programme, in case you
come across something like sexual orientation, you have to think twice before
you defend it."[181]

In a manner significant to the debates about "abstinence
until marriage," these warnings repeatedly focus around fears that gay or
lesbian people might actually marry.In
September 1999, after (inaccurate) published reports of a wedding ceremony
between two men in Uganda,
President Museveni told a conference on reproductive health:"I have told the CID [Criminal
Investigations Department] to look for homosexuals, lock them up and charge
them."[182]Several people were jailed in the wake of
this mandate.Five men and women who had
formed a tiny lesbian and gay group were tortured by police. Others fled the
country in fear.[183]

This environment of intimidation has a particular effect on
young people.In December, 2003, an
eighteen-year-old secondary school student in Nysamba was, according to press
accounts, "caned several times in front of a whole school after the administration
told her parents that she has been found with love letters from her fellow
girls."Suspended from classes, she was
later found dead in her bed shortly thereafter; while officials ruled the death
a suicide, activists in Uganda
suspected she may have died as a result of the beatings.[184]The press also reported that "A school
in Lubaga Division punished four girls after finding out about their love
affair.They were made to dig up three
ant-hills plus received 30 strokes at the assembly.Another one in Makindye expelled six lesbians
and two gays."[185]Fear of gay and lesbian students is actively
fostered by the government.In February
2005, for instance, a Ministry of Education official warned direly in a speech
about the "spread of homosexuality and lesbianism in secondary boarding schools."[186]

Despite the interlinked ignorance and fear surrounding, and
silencing, homosexuality in Uganda,
Human Rights Watch interviewed numerous young people in secondary schools and
universities, as well as young people out of school, who identified as gay or
lesbian and were sexually active.Young
gay and lesbian Ugandans reported discrimination and ostracization by members
of their communities, fear of seeking health services, and arrest and
intimidation by law enforcement officials for suspicion of engaging in
criminalized homosexual acts.The
following statements, directed to Human Rights Watch researchers during the
course of these interviews, all underscore the need to provide accurate
prevention information on how HIV is transmitted:

The HIV/AIDS information we get says that girls under
twenty are more susceptible to HIV than boys, so some guys think they can't get
HIV from another boy, is this true?

At school, they talk about sex in the vagina but not anal
sex, is it true you can't get HIV from anal sex?

I never knew that anal sex was a riskier form of HIV
transmission than vaginal sex.

I didn't know you could get an STD from anal sex, this
has never been explained to us.[187]

Former and current street children interviewed by Human
Rights Watch also said that street children often had sex with other children
of the same sex, or with adults who paid boys for anal intercourse.One former street boy in Kampala said he used to engage in anal sex
with older boys when he lived on the street, as well as with boys his age.He said that he had no information that
penetrative anal sex put him at risk of HIV because in Uganda, "this is just not talked
about."[188]Another former street boy in Mbale said:

These homosexual acts occur all the time.You might have a man who wants to have sex,
so he will pay a street boy a small amount of money to penetrate him.This could be anyone, a boda-boda [bicycle
taxi] driver, a street cleaner, even an educated man.Some people think that by having homosexual
relations, they are not going to get HIV. . . . Street children need
information on the dangers of sharing razors, of not picking up from dump
sites, and on using condoms correctly.They need this information to survive, not abstinence messages.[189]

Individuals involved in providing HIV/AIDS information to
young people said that the political climate and criminality associated with
homosexuality made it impossible to convey accurate HIV/AIDS information to
gays and lesbians.This did not stop
some courageous secondary school students from occasionally requesting
information from them about homosexuality and HIV/AIDS, however.[190]One activist working in an academic
institution told Human Rights Watch:

Men who have sex with men are erased from all HIV
programs.The Uganda AIDS Commission
does not want to hear about them.It is
a fact that here in Uganda
there is a percentage of men who are in heterosexual relationships but are
having sex with men on the side.This
puts women involved with them at heightened risk of contracting HIV.But nobody wants to talk about that in Uganda.[191]

Indeed, in November 2004, the Minister of Information said
publicly that he had written both the Joint United Nations Programme on
HIV/AIDS, UNAIDS, and the Uganda AIDS Commission to protest any "support for
lesbian, gay, bisexual and transgender groups," warning: "The government
position is very clear, homosexuality is illegal."[192]In response, the Uganda AIDS Commission told
the press that they "had no mandate to create a policy supportive of gays when
their activities were not recognized under national laws."[193]

HIV/AIDS materials in Uganda's schools, including the
PIASCY materials described above, provide inadequate information on how people
who engage in anal and oral sex can protect themselves from HIV, regardless of
their sexual orientation.In the PIASCY
upper primary teacher's book, the only reference to anal sex or homosexuality
is located in the chapter entitled "Morally Unacceptable Sexual Behavior for
Young Adolescents."The chapter provides
a list of "immoral behavior," including sexual activity between people of the
same sex.[194]The draft secondary materials for PIASCY
state that HIV transmission can occur through anal sex because the lining of
the anus is delicate and likely to be bruised during sex.There is no information provided, however,
that condoms and lubricant when used correctly and consistently can prevent the
transmission of HIV from anal sex.[195]

VII.
Restrictions on Condoms

As long as they're
calling it ABC and not bashing condoms, that would be no problem.What would be a problem is to deny support
for condoms.

There is no common
ground between contraception educators and authentic abstinence educators.That is because, like oil and water,
abstinence and condoms never mix.

-Leslee Unruh, president,
Abstinence Clearinghouse, January 2005

A year ago, ABC was
still cool in Uganda.Now, C is out of the equation.

-Anonymous, representative of a
U.S.-funded HIV/AIDS organization, Kampala,
November 2004

Among the many pitfalls of abstinence-only programs is their
outright denigration of condoms, the only device proven to prevent sexual
transmission of HIV.Latex condoms are
not a complete solution to HIV/AIDS, but they provide an essentially
impermeable barrier to HIV pathogens and if used consistently reduce the risk
of HIV transmission by 80-90 percent.[196]Condom use also reduces the risk of other
STDs that increase HIV vulnerability.Vigorous efforts to promote condoms in Uganda have resulted in dramatic
increases in knowledge, attitudes, and behaviors towards condom use,[197]
achievements that are widely credited with helping to reduce HIV incidence and
sustain relatively low rates of infection.[198]While much work remains to be done in closing
the gap between people's knowledge of condoms and their ability to obtain them,
it is encouraging that in the period from 1995 to 2000, increases in rates of
premarital sex in Uganda
were accompanied by greater condom use among sexually active young people.[199]

Far from building on its previous success in condom
promotion, however, the Ugandan government has taken numerous steps to impede
access to condoms for those at risk of HIV.In a series of highly publicized statements throughout 2004, President
Museveni lashed out against condoms as "inappropriate for Ugandans" and
suggested that condom distribution encouraged promiscuity among young people.[200]These comments caused considerable controversy
at the July 2004 International AIDS Conference in Bangkok, Thailand, where
Museveni told delegates he saw condoms as "an improvisation, not a solution" to
HIV/AIDS and that he favored "optimal relationships based on love and trust
instead of intentional mistrust which is what the condom is all about."[201]Following the conference, Museveni told a
local newspaper that "this condomisation . . . is a recipe for disaster."[202]

While Museveni's strongest criticism has been directed at
those who distribute condoms in schools (against whom he has vowed open "war"),
he has repeatedly claimed that condoms are appropriate only for women in
prostitution.[203]First Lady Janet Museveni, a vocal proponent
of abstinence-only approaches, has criticized condoms even more vociferously
than her husband.In August 2004, the
first lady criticized people who distribute condoms to young people for
"pushing them to go into sex" and stated that "it is not the law that our
children must have sex."[204]Shortly after, she criticized condom
distributors for sending "vague messages" about HIV prevention and for
concealing condoms' ineffectiveness against human papilloma virus (HPV).[205]

Official statements against condom use contradict the Uganda
Ministry of Health's National Condom Policy and Strategy (June 2004), which
states that "correct and consistent condom use shall be widely and openly
promoted to all sexually active individuals as an effective means of preventing
HIV/STI transmission and as a family planning method."[206]In February 2005, Uganda's Secretary of Health,
Godfrey Masaba, asked politicians to stop criticizing condom use, stating,
"Let's not bring politics in health issues by discouraging condom use.If the youth can't abstain, why not use condoms?"[207]

On at least one occasion, the Ugandan government has
supported an organization that spreads false information about the
effectiveness of condoms against HIV.The Family Life Network, a faith-based organization that claims to have
received a grant from the Ugandan government supported by the Global Fund to
Fight AIDS, Tuberculosis and Malaria, teaches young people that latex condoms
contain microscopic pores that can be permeated by HIV pathogens.In an interview with Human Rights Watch,
Stephen Langa, the director of FLN, presented a diagram comparing the small
size of an HIV pathogen with the larger particles of sperm, syphilis and
gonorrhea and stated, "I know that the holes are there [in condoms].I think I've seen several reports saying the
holes are there.Some of the holes, from
what I hear, are big enough for the virus to go through. . . . It's a
possibility."[208]In addition to receiving Ugandan government
support through the Global Fund, Langa is one of five authors of the country's
draft policy on abstinence and faithfulness.

In numerous interviews, non-governmental organizations that
have traditionally promoted condoms in Uganda told Human Rights Watch they
feared government restrictions if they continued their work."We fear we don't want to be seen to be doing
what government or political leaders are opposed to," the coordinator of a
youth HIV prevention program told Human Rights Watch.He added, "We fear we would be
blacklisted.At the end of the day, . .
. the Ministry of Education can say certain organizations cannot work in
schools because they do ABC.So we will
lose the grip of our constituency."This
coordinator said that his organization had stopped promoting condoms directly
to young people by May 2004."The vigor
with which condom use was talked about is now coming down," he said."Youth say, 'I hear about abstinence, but I
cannot abstain.We want condoms.'"[209]

Another organization that had promoted condoms in Uganda
since the early 1990s told Human Rights Watch that the recent shift toward abstinence
was reversing their success in gaining acceptance of condoms among young
people."We're almost back to square
one," one of the organization's staff members said, adding:

[B]ecause of our culture, it was very difficult for us to
get people to use condoms.Now, trying
to promote abstinence in this social environment . . . is very difficult.If you tell people to abstain, they'll say,
"You were the people telling us to use condoms, and now you're telling us to
abstain.Does this mean condoms weren't
effective and you were lying to us?"[210]

Numerous groups attributed the current pressure to promote
abstinence-only approaches to the influence of U.S. funding."If you're talking more about abstinence, you
will get more money," said a member of a youth group in Kampala that had received sub-grants from a
USAID-funded organization."The [U.S.]
funding pushes you to adopt certain strategies."[211]A service provider from a Ugandan
organization that does not rely on U.S. funds said that the trend
toward abstinence messages had not yet affected them, but still could."We are quiet now with our message and
waiting to see what will happen," she said.[212]

Numerous HIV/AIDS groups in Uganda
told Human Rights Watch that the activities of Population Services International
(PSI), a large U.S.-funded social marketing organization that sells subsidized
condoms under the brand-name Protector,
had been curtailed in recent months under pressure from the U.S. and Ugandan governments.A religious leader observed that PSI's billboards,
advertisements, TV commercials, and other materials promoting condoms had
disappeared in recent months."What a
coincidence," he said."At a time when
public officials are making statements against condoms, . . . all of a sudden, Protector is withdrawing their
billboards."[213]It is widely discussed among AIDS service
providers in Kampala that First Lady Janet Museveni had accused PSI of
distributing condoms at a promotional event designed to encourage abstinence
among youth, and that the accusation had resulted in restrictions on PSI's HIV
prevention work.

In addition to embracing abstinence messages and denigrating
condoms as an HIV prevention strategy, the Ugandan government in October 2004
issued a nationwide recall on all government-funded condoms.Allegedly in response to failed quality
control tests, this recall applied to all Engabu
(Shield) brand condoms, the main source of free condoms in Uganda.[214]Engabu
condoms had been in use in Uganda
since 1991; according to the National Drug Authority (NDA), the tests were
prompted by recent consumer complaints about the condoms' smell.Shortly after the recall, the NDA issued a
new policy requiring pre-shipment and post-shipment testing of all condoms
being imported into Uganda.Millions of condoms were impounded in
warehouses in Kampala
while they awaited NDA clearance, a process that was expected to take
approximately six months.

By December 2004, HIV/AIDS experts in Uganda were forecasting a national
condom shortage.[215]Numerous HIV/AIDS organizations visited by
Human Rights Watch said they had either run out of free condoms or stopped
distributing them under government orders.While some parts of the Ugandan government took steps to address the
condom crisis,[216] others
seized on it as platform to promote abstinence and fidelity as preferable to
condom use.[217]Dr.
Alex Kamugisha, Uganda's
minister of state for primary health care, said in response to the crisis:

We want to slowly move away from the condom.As a ministry, we have realized that abstinence
and being faithful to one's partner are the only sure ways to curb AIDS.From next year, the ministry is going to be
less involved in condom importation but more involved in awareness campaigns;
abstinence and behavior change.[218]

Other ministry officials suggested that, pending a solution
to the Engabu crisis, Ugandans should
simply abstain from sex.For his part,
President Museveni responded to the Engabu
crisis by blaming the country's stagnating HIV prevention efforts on faulty
condoms, though he acknowledged that condoms can be effective if manufactured
properly:

I am told Ngabo [Engabu] is not good, it breaks.That is another crisis.I don't know who approved that type.It breaks and kills people.Whoever allowed the importation of that condom
into Uganda
is a killer.Maybe that is why the
prevalence rate has stagnated because people believed in the safety of such
condoms and found they break.There must
be a limit to condoms, but for sure if they are well manufactured they can
control AIDS.[219]

Some of these statements by government officials fueled
suspicion that the Engabu crisis had
been orchestrated to support the government's burgeoning abstinence
campaign.In late January 2005, a German
manufacturer of Engabu condoms,
Stephen Buchmann Medical Care and Services, defended the quality of its product
and threatened to take legal action against "those persons and organizations
responsible for maligning our otherwise good record."[220]Others questioned whether the NDA's new
policy of requiring post-shipment testing of all imported condoms constituted a
proportionate response to concerns about Engabu's
quality.The coordinator of condom
procurement at the Uganda Ministry of Health, Vastha Kibirige, told Human
Rights Watch in November 2004 that the source of the alleged defective condoms
was under investigation.Kibirige added
that she was not at liberty to discuss the results of the quality control tests
or the policy discussion leading up to the government's response.

As of November 2004, the nationwide Engabu recall had already had a noticeable negative impact on
condom promotion efforts throughout Uganda."There is a big outcry now," said a
representative of a youth association in FortPortal."People say they want condoms, but not Engabu.Only Protector is currently
available, and people can't afford to buy them."[221]A
religious leader who had distributed condoms and HIV/AIDS information to young
people told Human Rights Watch, "There are challenges now.If Engabu
is withdrawn, . . . access to condoms will be difficult.Every time we go into the field we carry a
box of condoms with us, and already the demand is more than we can provide."[222]Even officials of the U.S. State Department
and USAID expressed concern about Uganda's decision to require post-shipment
testing of all imported condoms (a decision that delayed distribution of
U.S.-funded condoms that had been tested prior to shipment), but as of November
2004 their efforts to advocate against this policy had not borne fruit.[223]

Even the perception of opposition to condoms in Uganda, a regional leader in HIV prevention, has
the potential to fuel anti-condom sentiment in other parts of Africa.In January 2005, the head of the Catholic
Bishops' Conference of South Africa, Cardinal Wilfred Napier, cited Uganda
as an example of why the South African government should not be promoting
condoms.Napier reportedly stated, "If
we look at the one example of success [against AIDS] we have which is Uganda
then there is a clear message that it was a return to moral values that halted
the disease.Where condoms have been
promoted, we have not seen the effect we've seen in Uganda."[224]Just days earlier, Pope John Paul II had
reaffirmed the Roman Catholic Church's opposition to condoms for HIV prevention
as part of its larger opposition to birth control.[225]

VIII.
Arguments For and Against Abstinence-Only Programs

Encouraging young people to delay sex and reduce the number
of their sex partners forms a rational part of any comprehensive approach to
HIV prevention.However, governments
have an obligation not to censor or distort information about effective methods
of HIV prevention, including condoms, and to pursue HIV prevention strategies
that are scientifically valid.When
moral considerations (such as discouraging sex for its own sake or promoting
the institution of marriage) overwhelm sound HIV prevention, this impedes the
realization of internationally recognized human rights, including the right to
information, the right to the highest attainable standard of health, and
ultimately the right to life.

The following sections address two aspects of whether
abstinence-only-until-marriage programs constitutes a sound approach to HIV
prevention that is consistent with internationally recognized human rights:
first, whether abstinence messages in fact contributed to Uganda's decline in HIV prevalence in the 1990s;
and second, whether abstinence-only programs for young people have proven
effective in the United
States, where they have existed since 1981.

Distortion
of Uganda's HIV prevention efforts

Between 2002 and 2004, the U.S.
government sponsored at least four studies which concluded that the drop in HIV
prevalence in Uganda in the
1990s resulted from increased rates of abstinence and fidelity in Uganda
during that period, as well as a concerted government effort to encourage these
behavior changes.[226]The aim of these studies was apparently to
provide a scientific basis for current abstinence-until-marriage programs.The most recent of these studies claims that
Ugandan youth adopted at least twelve "protective behaviors" between 1989 and
2000, nine of which may be grouped under the category of abstinence or
fidelity.[227]The remaining three behavior changes relate
to increased condom use, though the study notes that few national data are
available on condom use before 1995.The
study does not attempt to ascertain the causes of various behavior changes
(e.g., government-funded HIV prevention campaigns versus broader social
factors), nor does it measure the relative impact of different behavior changes
(e.g. abstinence versus condom use) on HIV spread.It concludes that "[i]t is likely that a
combination of abstinence and partner reduction resulted in the decline in prevalence,
but that the increase in condom use helped maintain the low prevalence levels
throughout the rest of the nineties."[228]

There are multiple problems with using survey data such as
these as the basis for U.S.-funded abstinence programs.First, the U.S.
government's own research suggests that condoms played an important role in Uganda's
HIV decline, and not only for "high-risk" populations such as sex workers.[229]According to the above study, the percentage
of all sexually active Ugandan women and girls who had ever used a condom
increased from 9 percent in 1989 to 26 percent in 1995, a period that saw a
significant decline in HIV prevalence.Among men and boys, the percentage rose from 22 percent to 35
percent.While consistent condom use is
difficult to measure, a helpful indication of the contribution of condom use to
HIV prevention is the percentage of sexually active Ugandans who used a condom
the last time they had sex with a non-regular partner.National data for this indicator are
available only for the period 1995 to 2000, during which the percentage rose
from 25 percent to 44 percent among women and 40 percent to 62 percent among
men.As noted above, this increase in
condom use coincided with a steep increase in non-regular sexual partnerships
among young men, suggesting it staved off a significant number of new HIV
infections.Median HIV prevalence among
ante-natal clinic attendees dropped from 11.8 percent to 5 percent during this
period, though incidence (new HIV infections) likely dropped earlier.National data on increased condom use are
supported by studies in specific regions.[230]

Second, of the primary behavior changes documented in Uganda
in the 1990s, partner reduction (or a reduction in casual sex) appears to have
played a much larger role in HIV decline than abstinence.One indication of this is that teenage
pregnancy rates did not fall in Uganda
during this period, and that teenage girls who became pregnant did not do so at
older ages.This suggests that any drop
in HIV prevalence among girls could not have been due to girls' postponing sex
or becoming less sexually active, but instead to their having sex in more
regular partnerships.[231]Mathematical models have suggested that
having multiple non-regular sex partners can dramatically increase HIV spread,
more than having one regular partner after another (i.e., "serial
monogamy").The fact that Uganda
engaged in an intensive campaign in the 1990s to promote fidelity (known
locally as "zero grazing") further suggests that fidelity, not abstinence, was
the most successful component of its HIV prevention efforts.

Third, demographic data on the causes of HIV decline in Uganda
do not substitute for evaluations of abstinence-only programs.Program evaluations require a comparison of
the attitudes, intentions, and sexual behaviors of program participants over time, as well as in comparison to those who have
not participated in abstinence-until-marriage programs.Evaluations of this nature have been
occurring in the United
States since the 1990s and are reviewed
below.They indicate that
abstinence-only programs have little to no impact on participants' sexual
risk-taking behaviors, and that participants are less likely to use condoms
once they become sexually active.If
these are a guide, abstinence-only approaches would have been more likely to
detract from Uganda's
HIV decline than to contribute to it.

Finally, the HIV prevention campaigns implemented by the
Ugandan government in the 1990s, which enjoyed some success, differ vastly from
abstinence education as defined and implemented by the United States.Historical accounts, including those funded
by the U.S.
government, disclose numerous components of what has been described as the
"Museveni" approach to HIV prevention.[232]A hallmark of this approach was the
president's personal commitment to fighting AIDS, combined with his engagement
of numerous government ministries, active encouragement of NGOs and faith-based
organizations, and relaxation of state controls on mass media.The openness of Uganda's approach allowed a diversity
of prevention messages (including the "zero grazing" message noted above) to
permeate the country's schools, churches, and airwaves.Central to the effort was breaking down the
stigma associated with HIV/AIDS and encouraging frank discussion of sex and
other causes of HIV transmission.As one
veteran AIDS educator described it, "It's not true that Museveni talked about
abstinence.What he did was give us
complete freedom of the press.There
were pictures of vaginas and penises everywhere."A government minister added, "It was not easy
[at first] because culturally we don't talk about sexual matters openly.The church didn't want to talk about
condoms.Eventually, we managed to break
through.[Especially] once we explained
the multiplicity of methods of acquiring AIDS, the stigma reduced."[233]It would be a revision of history to suggest
that U.S.-funded abstinence-only programs, which were pioneered in the U.S. in 1981 as a means of pregnancy prevention
and before HIV/AIDS was an epidemic, are a natural outgrowth of Uganda's
early anti-AIDS efforts.

Even the so-called ABC (Abstinence, Be Faithful, Condom use)
approach to HIV prevention, which is routinely cited by U.S. officials and
others as the "Ugandan approach," does not accurately capture Uganda's
anti-AIDS effort before 2002.In
November 2004, the AIDS educator cited above told Human Rights Watch, "About
one and a half years ago we started hearing about ABC, and we'd never heard of
it before.We were told this is what Uganda's
model was." Another educator, who had
directed USAID-funded HIV prevention programs in Uganda since the early 1990s, said:

In about 1999 or 2000 . . . someone made a reference to
ABC, and I had to ask what ABC was.Although everyone says we were doing it in Uganda, I'd never heard of it.I don't even know where it came from.A faith-based organization recently said that
Janet Museveni had founded ABC, and I thought, you must be joking.History has been substantially rewritten
here.[234]

It is true that some Ugandan HIV/AIDS materials dating to
the 1990s refer to "delayed sexual debut" as part of a comprehensive HIV
prevention strategy; however, this does not amount to a national ABC approach,
much less to abstinence-only-until-marriage as currently defined by the United
States.[235]

Reverend Gideon Byamugisha, an Anglican priest from Uganda who is known as the first African cleric
to reveal his HIV-positive status, said of Uganda's
alleged ABC strategy, "It makes me angry to hear that Uganda's success is because of ABC.
It goes far beyond that.It's the amount of effort, information,
attitudes changing, skills for self-protection, programming, VCT [voluntary
counseling and testing], blood transfusions, training counselors and doctors .
. . a supportive environment.Uganda's
success is not an 'either/or.'Everything is important."[236]

Ultimately, Uganda's
anti-AIDS efforts in the 1990s cannot be reduced to a particular government
intervention such as abstinence-only or ABC.As one commentator recently put it, "The government is but one player in
the fight against HIV-1.[237]There are hundreds of nongovernmental
organizations, religious groups, and community activists also working to
prevent the spread of HIV/AIDS in Uganda."[238]This multiplicity of voices stands to be
jeopardized by the government's emerging focus on abstinence as an exclusive
method of HIV prevention.More
importantly, the implication behind abstinence-only programs that AIDS is a
"moral" disease stemming from "promiscuous" behavior is the antithesis of Uganda's
effort to de-stigmatize AIDS early in the pandemic.

Studies
discrediting abstinence-only approaches in the U.S.

The exportation of abstinence-only programs from the United States to Uganda is occurring notwithstanding
unrefuted evidence of the ineffectiveness and potential harms of these
programs.Government-funded evaluations
in at least twelve U.S.
states, as well as a federally mandated independent evaluation authorized in
1997, indicate that abstinence-until-marriage programs show no long-term success
in delaying sexual initiation or reducing sexual risk-taking behaviors among
program participants, and that program participants are less likely to use
contraceptives once they become sexually active.[239]The Institute
of Medicine, a body of experts that
acts under a Congressional charter as an advisor to the U.S. federal government, noted in
2001 that there was no evidence supporting abstinence-only programs, and that
investing "millions of dollars of federalfundsin abstinence-only programs
with no evidence of effectiveness constitutes poor fiscal and health policy."[240]Assessments such as these provide some
indication of the likely success (or failure) of abstinence-only programs in
Uganda, as U.S.-based abstinence-only programs are administered according to
the same guidelines, and in some cases by the same organizations, as proposed
Ugandan programs.[241]No independent evaluations of abstinence-only
programs exist from Uganda,
largely because such programs did not exist there on a significant scale before
2004.

Evaluations of abstinence-only programs typically measure
whether program participants change their sexual attitudes, intentions, and
behaviors over the short and long term.[242]According to a 2004 review of abstinence-only
program evaluations conducted by Washington, D.C.-based Advocates for Youth,
only one program showed any impact on participants' sexual behavior, and this
impact disappeared by the end of the program.While some programs had short-term impact on participants' attitudes and
intentions to abstain, and one (in Pennsylvania)
had some long-term impact on intentions, these attitudes and intentions did not
translate into behavior changes.[243]In one county in Pennsylvania, 42 percent of female
participants were sexually active by the second year of their abstinence-only
program.In another, rates of sexual
debut among females increased from 6 to 30 percent as program participants
progressed from seventh to ninth grade.In Minnesota,
where an abstinence program showed mixed results on changing attitudes towards
abstinence in the long-term, the percentage of youths who were sexually active
was higher in several counties with abstinence programs than the state average.[244]

Of equal concern is that abstinence-only programs may
discourage young people from using contraception once they become sexually
active.As noted above, abstinence-only
programs do not provide participants with information about contraception other
than (sometimes exaggerated) failure rates.In one county in Pennsylvania,
only half of those who said they started having sex in ninth grade used any
form of contraception.The Missouri evaluation
found that program participants developed a less favorable attitude toward
birth control from the beginning to the end of the program.Virginity pledges, a staple of
abstinence-only programs in which students pledge to remain sexually abstinent
until marriage, have been shown in peer-reviewed national surveys of adolescent
sexual behavior to reduce the likelihood of contraceptive use once pledgers
become sexually active.[245]

Proponents of abstinence-only programs often claim that
teaching young people about condoms and safer sex will contradict or otherwise
undermine the message of abstinence.However, studies that compare abstinence-only education with programs
that include factual information about contraception show the latter to be more
effective on all counts.A 2001 report
analyzing studies of HIV prevention programs found that programs that include
information about both abstinence and condoms can delay the onset of sex and
increase condom use among sexually active teens.The same study found no evidence existed that
abstinence-only programs had an effect on sexual behavior.[246]A 1998 study comparing a program that
educated students about safer sex (including condom use) with an
abstinence-only program found that both programs affected sexual behavior in
the short term, but that the safer sex program was more effective at reducing
unprotected sexual intercourse and frequency of intercourse in the long term.[247]

In 2001, the Institute
of Medicine concluded
that scientific studies have shown that comprehensive sex and HIV/AIDS
education programs and condom availability programs can be effective in
reducing high-risk sexual behaviors.[248]A 1997 report by the Joint United Nations
Programme on HIV/AIDS (UNAIDS) found evidence that sexual health education for
children and young people that included the promotion of condom use and safer
sexual practices, did not increase participant's sexual activity.[249]

In 2004, a "gold-standard" review of HIV prevention research
by the Cochrane Collaborative Review Group on HIV infection and AIDS concluded
that "[p]rograms promoting abstinence were found to be ineffective at
increasing abstinent behavior and were possibly harmful; more rigorous research
is needed to determine the effectiveness of abstinence programs on HIV risk."[250]A 2004 consensus statement in The Lancet signed by numerous experts in
HIV prevention from around the world, stressed abstinence as a "first priority"
for young people who are not sexually active but concluded:

For those young people who are sexually active, correct
and consistent condom use should be supported.Young people and others should be informed that correct and consistent
condom use lowers the risk of HIV (by about 80-90% for reported "always use")
and of various sexually transmitted infections and pregnancy, and they should
be cautioned about the consequences of inconsistent use.[251]

Officials of the U.S. government did not endorse the
Lancet statement, though they were
asked to do so.

U.S.
officials systematically ignore independent evaluations of abstinence-only
programs, instead making broad and unscientific claims about the benefits of
abstinence.The U.S. global AIDS strategy, for
example, posits that "[d]elaying first sexual intercourse by even a year can
have significant impact on the health and well-being of adolescents and on the
progress of the epidemic in communities."[252]Beyond failing to cite evidence for this
claim, the strategy neglects to mention that some countries with higher average
ages of sexual debut than Uganda-Zimbabwe and South Africa, for example-have much
higher rates of HIV incidence.The
important point is that delaying sex does not protect people from HIV unless
they protect themselves once they become sexually active.Abstinence-only programs in fact increase HIV
risk by withholding information about contraception and safer sex and by
suggesting that married people are safe from HIV infection.

As further "proof" of abstinence-only programs, proponents
frequently cite evidence of reduced teen pregnancy rates in the United States
in the 1980s and 1990s, a period that saw increased federal funding for
abstinence-only programs.[253]This logical fallacy assumes that just
because abstinence-only programs occurred at the same time as a reduction in
teen pregnancy, they must have caused this reduction.Indeed, studies also show that contraceptive
use increased during the same period, and (as noted above) that rates of
premarital sex are higher in some regions with abstinence-only programs than in
those without these programs.The fact
that participants in abstinence-only programs are less likely to use contraception
once they become sexually active suggests that teen pregnancy rates might have
dropped even further were it not for these programs.

IX.
Government Response

Human Rights Watch interviewed a number of government
officials about the implementation of abstinence-only programs in Uganda
and the wide range of objections to these programs.Officials representing the offices of the
president and first lady, together with representatives of the Ministry of
Health, the Ministry of Education, the Ugandan Parliament, and the Uganda AIDS
commission, spoke favorably of the country's increasing emphasis on abstinence
and being faithful as a way of preventing new HIV infections among youth.

Some government officials expressed the view that
abstinence-only programs did not and should not detract from providing
information about other prevention strategies, and that a comprehensive
strategy represented Uganda's
approach to HIV prevention.This
position was well summarized by Dr. Elioda Tumwesigye, chairperson of Uganda's
Parliamentary Committee on HIV/AIDS, who said:

I support a balanced approach.If everyone could abstain that would be fine,
but not everyone can or will, so why not emphasize condoms instead of having
young people go live [without condoms]?Let us make every tool available for every program to have full and
correct information available.Unless
someone brings information that talking about condoms increases sexual
practice, than we shall promote condoms, too.[254]

Human Rights Watch asked numerous government officials if
they were aware of research studies done in the United States that had discredited
abstinence-only approaches or shown them to be potentially harmful.No official was aware of the studies.When asked how they would respond to the
studies, some stressed that Uganda
was a different society than the United States with different morals
and values.Research needed to be done
on abstinence-only programs in Africa, they
said.Most agreed that the United States
had been a strong driving force behind Uganda's abstinence policy, and that
certain U.S. policy makers had alerted decision-makers in Uganda to the
supposed benefits of abstinence-only approaches.[255]

Asked whether abstinence messages were appropriate for all
young people, even young people whose poverty, displacement, sexual
exploitation, and orphanhood increased their risk of HIV/AIDS, officials
responded that messages were individually tailored for the intended
audiences.One official said:

For prostitutes and others, we tell them to go ahead and
use condoms.Abstinence messages are for
the appropriate sectors in society, for those who can strengthen themselves
with these messages.These messages are
for those in school, those with both parents living who are going to be receiving
higher education.[256]

Human Rights Watch also asked officials to respond to the
objection that abstinence-only programs promoted stigma against people living
with AIDS by implying that HIV infection resulted from "sinful" or "immoral"
behavior.A member of the Uganda AIDS
Commission acknowledged that it was possible some people would feel
stigmatized.She added, however, that
morality needed to be addressed in HIV prevention because, as she put it, some
people who "lack morals" might pass the infection on to others who are
"innocent."[257]

The concern that abstinence-only approaches undermined the
promotion of condoms also failed to resonate with Ugandan officials.A representative of the First Lady's Office
stated, "I have my rights too.I am
personally angry when I feel people are pushing condoms on me.People who talk about abstinence believe in
it.We are offended by those
organizations that promote condoms."[258]

X. Conclusion

As an activist and
woman living with AIDS, it makes me feel judged.You are supposed to abstain and be faithful.Condoms are only for those who are
promiscuous.I got HIV in marriage.I was faithful in my relationship.The battle to come out and be open was a
struggle.Now, instead of moving
forward, we are moving strides back.

-Ugandan woman living with AIDS

Uganda
is unique among African nations for its early and high-level leadership against
HIV/AIDS.The government's willingness
to address HIV/AIDS openly and break taboos surrounding sexually transmitted
diseases is widely acknowledged as the cornerstone of its early success against
the epidemic.By involving a wide range
of nongovernmental organizations in the AIDS struggle and allowing candid
messages about sex to reach a wide audience, Uganda achieved high levels of
awareness of HIV, increased voluntary HIV testing, and ultimately fewer new HIV
infections.

Today, this progress may unravel as U.S.-funded
organizations scale up programs that promote sexual abstinence and fidelity
within heterosexual marriage to the exclusion of all other HIV prevention
strategies.These programs deprive young
people of information that could save their lives.They mock the plight of countless Ugandan
women and girls who abstain until marriage and are faithful within it but
nevertheless become infected with HIV.They provide scant information or assistance to those at highest risk of
HIV infection, including street children who trade sex for survival, children
affected by conflict, and lesbian, gay, bisexual, and transgender youth.They distort factual information about
condoms and safer sex strategies, placing young people at a higher risk of HIV
and other sexually transmitted diseases.

As their proponents admit, abstinence-only programs are not
simply about preventing HIV/AIDS, but about promoting moral values.However, censoring or distorting factual
information about HIV/AIDS is not a moral value.Moreover, casting HIV/AIDS as a "moral"
disease that results from "promiscuity"-as abstinence-only programs invariably
do-reinforces the deadly stigma associated with HIV/AIDS.Throughout the 1990s, Uganda stood for the idea that AIDS
could affect anyone, not simply "promiscuous" people.This idea proved critical to respecting the
human rights of people living with AIDS and protecting them from violence and
discrimination.Now, abstinence-only
programs give Ugandans a new reason to stigmatize people living with AIDS and
to judge their actions as immoral or blameworthy.

To its credit, Uganda continues to recognize that
its young people face a high risk of HIV infection and has faced up to that
challenge by expanding school-based sex education programs.However, as a perceived global leader in HIV
prevention, Uganda
is accountable to evidence and best practices in HIV prevention.The country's high-profile U-turn toward
unproven HIV prevention strategies for young people has, at this writing,
already begun to resonate throughout other parts of Africa.Its complicity in the rewriting of history
around its HIV prevention "success" could have implications on HIV prevention
programs for years to come.Ultimately,
it is not just Ugandans who will pay the price for the country's back-steps in
HIV prevention.It is the entire effort
against the global AIDS pandemic.

Acknowledgments

This report was researched and written by Jonathan Cohen,
researcher in the HIV/AIDS and Human Rights Program, and Tony Tate, researcher
in the Children's Rights Division of Human Rights Watch.The report was reviewed by Lois Whitman, executive director of the Children's
Rights Division; Rebecca Schleifer, researcher with the HIV/AIDS Program; Janet
Walsh, deputy director of the Women's Rights Division; Scott Long, director of
the Lesbian, Gay, Bisexual and Transgender Rights Project; James Ross, senior
legal advisor; and Iain Levine, program director of Human Rights Watch.We are grateful to Joanne Csete, executive
director of the Canadian HIV/AIDS Legal Network, and Helen Epstein for their
helpful comments.Jennifer Nagle,
Veronica Matushaj, Andrea Holley, and Fitzroy Hepkins provided production
assistance.

Human Rights Watch extends its gratitude to the young people
in Uganda
who shared their stories and experiences with us.We also thank the many teachers, school
administrators, youth outreach workers, and service providers who spoke with us.Without them this report would not have been
possible.

Human Rights Watch gratefully acknowledges the willingness
of the offices of the president and first lady, the ministries of health and
education, the Uganda AIDS Commission, and the Uganda Human Rights Commission
to share their views with us for this report.Among the dozens of nongovernmental organizations, service providers and
religious leaders who contributed to our field research, we extend particular
thanks to the Naguru Teenage Centre, Uganda Youth Development Link, AIDS
Information Center, The AIDS Support Organization (TASO), Africa Youth
Alliance, the Uganda Youth Anti-Aids Society, Save the Children, National Youth
Organization for Development, the Kabarole Research Centre, and the Lyamabwa
Youth Center.

We recognize with appreciation the funding provided for our
work by the Oak Foundation and the Independence Foundation.

[1]
The U.N. Convention on the Rights of the Child states: "For purpose of this
present Convention, a child is every human being below the age of eighteen
years unless under the law applicable to the child, majority is attained
earlier." Convention on the Rights of the Child, Article 1, adopted November
20, 1989 (entered into force September 2, 1990).

[4]
Estimates of national HIV prevalence in Uganda vary.In 2002, the STD/AIDS Control Programme of the
Uganda Ministry of Health estimated that 6.2 percent of the national population
was infected with HIV.It should also be
noted that trends in HIV prevalence are not as good a measure of HIV prevention
as trends in HIV incidence, which measure new HIV infections in a given
year.STD/AIDS Control Programme, 2003 HIV/AIDS Surveillance Report, p. 6.

[10]
Those surveyed were women between twenty and forty-nine, and men between twenty
and fifty-four.Uganda Bureau of Statistics (UBOS) and ORC Macro, Uganda
Demographic and Health Survey 2000-2001 (Calverton, MD:
UBOS and ORC Macro, 2001), p. 79.

[40]
Office of the United States Global AIDS Coordinator (OGAC), The President's Emergency Plan for AIDS
Relief: U.S. Five-Year Global HIV/AIDS Strategy (Washington, D.C.:
United States Department of State, 2004), p. 27.

[41]
H.R. 1298, United States
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, ss.
402(b)(3), 403(a).The Act does not
specify a level of assistance for HIV prevention, but it caps such assistance
at 20 percent of HIV/AIDS funds, or a maximum of U.S.$3 billion.

[43]
Sexuality Information and Education Council of the United States (SIECUS),
"Overall Federal Spending for Abstinence-Only-Until-Marriage Programs," State Profiles: A Portrait of Sexuality
Education and Abstinence-Only-Until Marriage Programs in the States (FY2003
edition).President Bush requested an
increase to U.S.$268 million dollars for abstinence-until-marriage programs for
FY2005.

[51]
See, e.g., Nicholas D. Kristof, "The Secret War on Condoms," The New York Times, January 10, 2003;
Marie Cocco, "White House Wages Stealth War on Condoms," Newsday, November 14, 2002; Caryl Rivers, "In Age of AIDS, Condom
Wars Take Deadly Toll," Women's eNews, December 10, 2003,
http://womensenews.org/article.cfm/dyn/aid/1633/context/archive (retrieved
February 16, 2004); Art Buchwald, "The Trojan War," The Washington Post, December 11, 2003.

[52]
Compare U.S. Centers for Disease Control and Prevention (CDC), "Condoms and
Their Use in Preventing HIV Infection and Other STDs" (September 1999),
available at
http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_orig.pdf
with CDC, "Male Latex Condoms and Sexually Transmitted Diseases" (2002),
available at
http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_revis.pdf.

[53]
Compare U.S. Agency for International Development (USAID), "The Effectiveness
of Condoms in Preventing Sexually Transmitted Diseases,"
http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condom_effect.html
(retrieved January 28, 2003) with USAID, "USAID: HIV/AIDS and Condoms,"
http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condomfactsheet.html
(retrieved July 10, 2005).

[55]
Compare CDC, "Programs that Work" (archived version at http://web.archive.org/web/20010606142729/www.cdc.gov/nccdphp/dash/rtc/index.htm)
with CDC, "Programs that Work" (http://www.cdc.gov/nccdphp/dash/rtc/).

[56]
See Rep. Henry A. Waxman, "The Effectiveness of Abstinence-Only Education," in Politics and Science: Investigating the
State of Science Under the Bush Administration, http://democrats.reform.house.gov/features/politics_and_science/example_abstinence.htm
(retrieved February 7, 2005);H.
Boonstra, "Public Health Advocates Say Campaign to Disparage Condoms Threatens
STD Prevention Efforts," The Guttmacher
Report on Public Policy, March 2003, p. 2.

[57]
Proponents of abstinence education have long sought to disparage condoms by
speculating about the link between condom usage and cervical cancer.The legislation authorizing PEPFAR compels
the president to report on the "impact that condom usage has upon the spread of
HPV in Sub-Saharan Africa," a mandate that many view as an effort to undermine
confidence in the use of condoms against HIV.H.R. 1298, s. 101(b)(3)(W).

[115]
Ministry of Education and Sports, PIASCYSecondary Schools,
p. 29.As an elective, children should
be free to choose CRE and follow their religious beliefs.Messages on HIV prevention for secondary
school students, however, should not be associated with judgment, stigma, or
religion but presented in a way that it applicable to all Ugandans.

[117]
President Museveni came to power in Uganda through a military victory,
has twice been elected president, and has led the country for nineteen
years.At this writing, legislation is
being debated in Uganda
that would amend the constitution and allow the president to run for a third
term in 2006.

[120]
The Movement can be loosely defined as a political organization rather than a
political party.All Ugandans belong to
the Movement, including those who oppose it.It has many characteristics of a ruling political party in a single
party state.In Uganda, there are strict
regulations on political activities and opposition parties which do not apply
to the Movement.For more information on
the Movement system in Uganda,
see Human Rights Watch, Hostile to
Democracy The Movement System and Political Repression in Uganda (New York:
Human Rights Watch, 1999).

[122]
The HIV/AIDS Integrated Model District Program (AIM), Report of the Fourth Presidential Dialogue with Young Leaders on
HIV/AIDS and Development, West Nile Region, Arua Public Primary School,
October 1113, 2004, pp. 32-33.

[130]
Executive Order 13280: Responsibilities of the Department of Agriculture and
the Agency for International Development With Respect to Faith-Based and
Community Initiatives, Federal Register, vol. 67, no. 241, December 12, 2002.

[132]Janet Museveni, "The AIDS Pandemic: Saving
the Next Generation," World Congress of Families,
New York, May
3, 2002, http://www.worldcongress.org (retrieved January 11, 2005).Anne Mugisa, "Janet to Host 70,000 Virgins," The New Vision, December 1, 2004, http://allafrica.com
(retrieved December 2, 2004).

[138]
Priya Abraham, "Hooked on Failure Africa: In Africa's Fight Against AIDS, the
United States Continues to Support Family-Planning Groups that Stifle the White
House Abstinence and Fidelity Message," World
Magazine, November 6, 2004, http://www.worldmag.com (retrieved December 8,
2004).

[140]
Human Rights Watch telephone conference with NGO in Kampala, February 8, 2005.Human Rights Watch was not able to determine
the full amount of U.S.
funding for the Youth Forum, whether channeled through in-country PEPFAR funds,
Washington-controlled funding, or both.

[142]
A December 2002 executive order governing federal funding of community and
faith-based organizations states that, in accordance with the U.S.
Constitution's separation of church and state, "organizations that engage in
inherently religious activities, such as worship, religious instruction, and
proselytization, must offer those services separately in time or location from
any programs or services supported with direct Federal financial
assistance."Executive Order 13279-Equal
Protection of the Laws for Faith-Based and Community Organizations, Federal
Register, vol. 67, no. 241, December 16, 2002.

[152]
This is occurring even though increasing proportions of young Ugandans are
postponing sex to a later age.The data
in this paragraph are taken from Uganda HIV/AIDS Partnership, Uganda Ministry
of Health, Uganda AIDS Commission, and MEASURE Evaluation Project, AIDS in
Africa During the Nineties: Uganda: Young people, sex, and AIDS in Uganda
(Chapel Hill, NC: MEASURE Evaluation,
Carolina Population Center, University of North Carolina at Chapel Hill, 2004,
pp. 60-62.

[159]
UNAIDS, UNICEF, and USAID, Children on
the Brink 2004, A Joint Report on New Orphan Estimates and a Framework for
Action (New York:
United Nations Publications, 2004), Fourth Edition, p. 30, http://www.unicef.org
(retrieved January 29, 2005).The word
orphan as used here described any child in Uganda who has lost one or both
parents.

[178]
It should be cautioned that many men who have sex with men, in Africa or
elsewhere, might reject or might not even know the terms "homosexual"
or "gay"; many women who have sex with women might not see themselves
as comprehended under the label "lesbian."In general, Human Rights Watch describes people by the identities they
ascribe to themselves; in using these terms here, we recognize that not
everyone facing abuse based on sexual orientation or gender identity would
recognize themselves in them.

[196]
See studies cited in PIASCY in secondary schools,
above.This does not mean there is a
10-20 percent chance of becoming infected with HIV from sex with a condom.It means that the chances of HIV infection
through an act of unprotected sex decrease by 80-90 percent with consistent
condom use.

[205]
Mugisa, "Abstain, Condom Not Safe."As
noted above, condom use is in fact associated with lower rates of cervical
cancer and HPV-associated disease, though the precise effect of condoms in
preventing HPV is unknown.

[227]
The nine behaviors are premarital sex, age at first sex, sexual debut before
age fifteen, age at first marriage, past year abstinence, past year secondary
abstinence (i.e. abstinence among those already sexually active), non-marital
partnerships, extramarital sex, and multiple partnerships.

[228]
UHP/MOH/UAC/MEASURE, Young people, sex
and AIDS in Uganda,
p. 49.Conclusions such as this are
unfortunately highly politicized.Studies not funded by the U.S. government have made more
nuanced conclusions from the same data; see, e.g., Susheela Singh, Jacqueline
E. Darroch, and Akinrinola Bankole, "A, B and C in Uganda: The Roles of
Abstinence, Monogamy and Condom Use in HIV Decline" (December 2003), Alan
Guttmacher Institute Occasional Report No. 9. While a comparative analysis of
these studies is beyond the scope of this report, theimportant point is that the U.S. government's own assessment
does not support the establishment of abstinence-only programs as described in
the U.S. Global AIDS Strategy.

[229]
As noted above, condoms are not part of abstinence education programs funded by
the U.S.
government, but rather are targeted at "high risk" populations.

[230]
In Rakai District, for example, condom use increased from 2 percent to 66 percent
of the sexually active population, a period that saw a decrease in HIV
prevalence to 12 percent from 44 percent.Sadab Kitatta Kaaya, "Rakai Condom Use Reaches 66 Percent," The Monitor, January 27, 2005.See also, Roehr, "Abstinence programs do not
reduce HIV prevalence in Uganda."

[231]
Helen Epstein, "The Fidelity Fix," The
New York Times Magazine, June 13, 2004, p. 56.The epidemiologists Rand Stoneburner and
Daniel Low-Beer have also elaborated this argument in a series of articles.

[235]
In late 2004, the British medical the journal The Lancet published a consensus statement on HIV prevention which
stated, "The ABC (Abstain, Be
faithful/reduce partners, use Condoms) approach can play an important
role in reducing the prevalence of HIV in a generalised epidemic, as occurred
in Uganda."Daniel Halperin et. al., "The Time Has Come
for Common Ground on Preventing Sexual Transmission of HIV," The Lancet, Volume 364, Number 9449,
November 27, 2004.It is unfortunate
that by using the term "ABC" in reference to Uganda, the statement contributed
to the misperception that the U.S. AIDS Strategy, which uses the term ABC,
follows the Ugandan approach.

[239]
See Mathematica Policy Research Institute, Inc., The Evaluation of Abstinence Education Programs Funded Under Title V
Section 510: Interim Report, p. 4, as well as state-level studies cited by
Advocates for Youth, below.A second
federal report was completed in 2004 and submitted to the U.S. Congress and
U.S. Department of Health and Human Services for review, but has yet to be released.

[240]
Committee on HIV Prevention Strategies in the United States, Institute of
Medicine, No Time to Lose: Getting More
from HIV Prevention (Washington, D.C.: National Academy Press, 2001), pp.
xi-xii and pp. 118-20.